A bit of housekeeping here. In the wake of the Cho shooting, there was much discussion on this blog, the wider blogosphere and the media about psychosis (which turned into a short hand for schizophrenia). At times, including in comments on this site, there seemed to be a lot of confusion over what psychosis is. Here's the Wikipedia entry on psychosis. The basic definition is:
1. Hallucinations.
2. Delusions and paranoia.
3. Thought disorder.
4. Lack of insight.
Cho certainly exhibited delusions, paranoia, thought disorder and a complete lack of insight. I am less clear from the information that's out there that he suffered from hallucinations (yes, he had a made-up girlfriend from space and said some crazy things about Vladimir Putin, but were those as a result of delusions or hallucinations?). Clinically, it's still not clear what was driving Cho. Autism? Asperger's? Schizophrenia? Depression? As I noted recently, my hunches center on psychosis NOS and Asperger's. I hope we do get an answer someday, a view well-articulated in this New York Times op-ed last week.
Blogger Robert Lindsay has done an excellent job of beating down the schizophrenia dx, although he denies that Cho was psychotic (two posts here and here). I think he was, but like Lindsay I am not convinced of the Fuller Torrey line that Cho was a classic paranoid schizophrenic.
Sadly, Lindsay mischaracterizes this blog as being "a good but anti-psychiatry-oriented blog (in other words, a typical mental health "consumer" blog)." Um, Bob, not true. But I knew that sooner or later someone would try and hang the anti-psychiatry albatross around my neck.
But if being for truth in mental health (such as an end to cooked research data and full-disclosure about potential injuries suffered on atypicals) and transparency in how the system is run (like not allowing Big Pharma and its minions to call all the shots) counts as "anti" behavior, then go find me a sea bird.
Here's an op-ed from yesterday's Boston Globe from a writer who claims she'd always thought stars and such suffering from exhaustion were doing it as a cover for bad habits. Her mind was turned around a bit by the case of Diane Patrick, wife of Mass. Governor Deval Patrick, who stepped out of public life a couple of months back after, according to accounts I've read, she worked herself into exhaustion and a bout of depression between maintaining a law practice and being First Lady. She's back in action now. The author is a wee bit less skeptical of exhaustion being excuse mongering now.
Americans are more productive than we have ever before been in our history, working well over 40 hours a week in many cases. And people wonder why there is plenty of depression, anxiety and general agitation to go around in America.
On a semi-related note, a reader passed along a site detailing the belief that caffeine over-use is at the heart of mental illnesses. I am fairly skeptical of such claims (there's a certain bit of horse sense there, but I'd like to see some thorough research as opposed to the thinly-detailed claims on the site. However, claiming that caffeine is related to psychosis is just nutso). If researchers would ever like to do a large real world study, then they ought to come to Seattle. I doubt that Starbuck's would underwrite the study. Joking aside, it is staggering just how much caffeine shows up in drinks these days--Red Bull, caffeinated waters and such--as opposed to the usual suspects of coffee, tea and soft drinks.
Jim Gottstein, the Alaska lawyer who helped get the Zyprexa documents into the public realm, is soon to receive an award from a Jewish temple in Alaska. Congrats to Gottstein, who is owed the thanks of many for forcing certain uncomfortable truths about Eli Lilly's drug into the world. He'll likely never get the award he richly deserves from the likes of NAMI or MHA.
Hell, he almost came out and said they suck. To whit, this from a presentation by James Jefferson, a psych researchers at the University of Wisconsin in Madison, at a conference in San Francisco:
"The mission for the condition is remission," said James W. Jefferson, M.D., of the University of Wisconsin in Madison, but "we are still stuck with this low remission rate.""Just getting a response with treatment, defined as reducing depression scores by at least half, is not enough, he said in a presentation here at the U.S. Psychiatric and Mental Health Congress regional extension.
As the article in Psychiatric Times notes, Jefferson cited the 7 percent to 30 percent remission rates seen in the STAR*D trial as evidence of what patients have known for years. Docs have known it too, but haven't been upfront about that in either sessions with patients or in public. I'm glad someone is.
Of course, Jefferson also spoke up in favor of an MAOI transdermal patch, so, um, whatever.
I went out for dinner and drinks with an old friend the other night. I was broke and she was buying. We hadn't really sat down and talked in 18 months or so. In the midst of talking about whatever ails post-modern society, she said, "You seem a lot less edgy these days."
"You mean less agitated?"
"Yeah. What happened?"
"It's those meds that I was on."
When she and I first met in 2002, I was on Risperdal and Lexapro, among others, and then later was on Wellbutrin and Seroquel. Then, in late summer 2005, I ditched everything except Lamictal. It was both an experiment (my doctor approved) and playing a hunch. Polypharmacy hadn't been kind to me--I'd gotten light EPS symptoms from both Risperdal and Seroquel, and anti-depressants had always started strong for me and, then, a couple of months later either stopped working or agitated the hell out of me (not that I went off them even then, mind you). I'd hit a fork in the road.
I looked at the whole thing as--I know I don't have my term quite right--a challenge, re-challenge protocol. If the one-med plus a lot of work on my end approach didn't work, then other options existed. None of them especially pleasant.
"Well, you seem a lot calmer."
"Yeah, it's funny."
"Why?"
"Well, docs are always giving people like me loads of meds. When things don't work well, they give you more of the same or another pill that's pretty much like every other pill. They are supposed to make us calm and stable. Didn't work that way for me."
"I like you better this way."
"Me too, I think. But we'll see how it goes."
I did fairly well as soon as I got off the hardcore dope--Lamictal is like water compared to Seroquel--and that weird restlessness that had dogged me for years was gone. For a few months, I figured it was all halo effect. But it's continued. That's nice. So was losing the puffiness in my face and the weight on my ass. I should've realized the obvious years before--that some meds and classes of meds make me a mess--and tried the same experiment when I was 38. Live and learn.
I'd say after almost two years of going this route that I am both--knocking on wood--recovered from meds and the dread disorder (well, 90 percent of the time) and in a position where my doc and I are reevaluating how I should go about things in the future. One med? No meds? Who knows?
The process I just laid out goes on far too infrequently in mental health care. Too often the blame for symptoms and lack of progress--the less than half remission that most patients experience--gets placed on the patient or the illness. I buy those arguments but only up to a certain point. Patients are doing themselves a disservice--and docs aren't doing right by their patients--if they don't approach a lack of clinical improvement over time with skepticism and a willingness to experiment. Both parties to the unspoken health care contract--you're going to get better and the patient controls the terms--are reluctant to strip away the layers of meds people are on. And the patients who are willing to do it often go about it all wrong and get put right back into the bad old cycle when they fall apart. But that's for another day.
Eli Lilly says it's provided the FDA with all relevant data concerning side effects of Zyprexa, including data related to yesterday's news that the company may have misreported some hyperglycemia data in 2000. What's weird is the person stating this on behalf of Lilly is the company's director for Iceland and Denmark. No press release from the company. Weird.
Stop the presses: Eli Lilly sponsored a survey of the most romantic cities in America, apparently in connection with its ED drug Cialis. Pittsburgh is number one. Seattle doesn't make the top 10--no shit!
Depression Introspection has an account of some nasty shit at a psych hospital. Ugh, read it. I cannot bring myself to summarize it. It's rough stuff.
Yet another excellent post from the Last Psychiatrist on Cho. It hits upon a theme which I'll take up later. He's definitely onto something.
Consumers Union has a press release out calling for the US Senate to reform FDA safety regulations via a pending bill. I hope the Senate does. Most useful would be some stricter post-marketing safety monitoring and reporting of patented medications. Among many other things.
A doc at UCSF pushes for more defined diagnoses in the DSM for hypomania and mixed states. A nice intellectual point, but this will do what for the average patient.
Yet another depression linked to pain study. Yeah, I know the docs have linkage data to support the thesis, but I think you can link depression to so many things. Stress, education, poverty, not getting laid and so on. But as long as the pain and depression thing doesn't lead to anyone with a bad back being thrown onto Cymbalta or something, then whatever.
Women who smoke during pregnancy are being pathologized. How about just calling them stupid?
The Harvard Mental Health letter asserts that bipolar disorder is difficult to diagnose in children. Up to 30 percent of kids dx'd as bipolar later receive an ADHD dx. Discuss in commments!
Meanwhile, a social worker in New York narcs out the psych profession for over-medicating kids.
Soulful Sepulcher has an interesting post on mental illness and religion.
Remember that study from last month showing that placebos outdid anti-depressants in treating depression in bipolar disorder? For some reason, it hit my Google alerts last night, as it had been published in the print edition of the New England Journal of Medicine. I guess it was published online in late March for other reasons. But I wonder if it might not lead to some kind of media notice, since the last time out most of the media failed to understand the implications of the study.
It was just the undoing of a medical paradigm after all--not a big deal at all--because for the last 17 years or so, whenever someone with bipolar disorder presented to a doc with depression, then they'd get an SSRI or anti-depressant of some kind. And, as most bipolars know, SSRIs and the like haven't done much to address depression. It's a point I made last time around.
It'll be interesting to see how it plays out this time. BTW, the original paper is no longer a freebie, but if anyone wants a copy of it, let me know in comments and I'll send you the pdf.
I heard from a friend of mine in Canada today. She'd been out at a club the other night and some criminal spiked her drink. With roofies, GHB or ketamine, she didn't know which. Nothing bad happened to her as a result, aside from missing two days of work. Her reaction to the drug/s was bad. But she'd been with friends and she passed out on them. I didn't ask for any more details. She hadn't ended up being beaten or raped. She was lucky. That was enough.
Who the hell are the guys who do this shit? Are they the same kind of crazy person--OK, person with mental illness--as Cho or are they another breed of delusional freak?
Of course, things go badly around date rape and date rape attempts for women too often. I know of a woman--a friend of a friend--who was slipped something in a drink in a Seattle club in a part of town called Pioneer Square. It's where the big clubs and suburban frat boys are on weekend nights. She was with friends that night and wasn't drunk. It was early. Somehow the guy got her into her own car (she doesn't remember that part) and the next thing she remembers it's 4 a.m. and she's being lifted into an ambulance about 40 miles from Seattle in a town in the Cascade foothills, her car crashed against a tree. She would never tell me any of it on the record, but I was convinced that it was going on enough in town to where I wanted to know a lot more about the phenomenon. Two other friends of mine in town had had the same basic thing happen to them in clubs here--not drunk, suddenly getting dizzy and passing out, friends to protect them and get them home, the next day spent in a fog wondering "How close did I come to being in real trouble?" as one of them put it to me once.
Pretty damn close.
It was a story I really wanted to get to the bottom of, but I could never find where a perpetrator had been busted for spiked-drink-at-the-club rape (You need a perp as much as you need a victim in a lot of stories). Other duties intruded. I moved on. The woman I mentioned at the top pushed it right back into my mind.
And it all makes me sick. The guys who do this are sick, mentally so in my opinion along the continuum of sociopaths. And a special form of scum. But they get away with it, all the time apparently. Yet this club phenomenon goes on and we all know it. If you can't tell by now, this kind of crap pisses me off.
I didn't even know what to say to my friend because this shit is so out there in the bad realm of human behavior--animal behavior may be the more correct term--that you don't know the words for it. I find it that hard to comprehend and give scope to. What kind of guy, after all, dresses up for the night, gets money from the ATM, drives downtown, pays his cover and goes indoors to look for a victim? A sick one, of course, as mentally fucked-up as was Cho.
These guys are sick in the way that Cho was (remember his weirdo stalker phase got him into the psych unit in the first place) and probably capable of a whole series of crimes other than rape and rape-by-drugs. This is the kind of crazy that goes to personality order more than psychosis and certainly has nothing to do with a mood disorder. It's the narcissist freak zone. And, for some reason, it's perfectly normal to them.
I don't have a larger point than that there must be some point in their development as human animals where it became OK to them psychologically to be that way, where in the same moment they could've rejected such ideas with as much force as they must have accepted them internally--listened to the better angels of their nature--and become a different human animal. That didn't happen.
Cho happened. Kyle Huff happened. My friend got slipped a roofie. Why?
And once their psychological resistance is broken--assuming they even understand such mind play as crossing a taboo--where do they then turn to find guidance? Do they talk about this with other guys and become initiated into the roofie cult? Did they read a novel, see particular movie or read some nonsense on the Net that appealed to them and showed them the way? Who was their mentor? Who sells these drugs knowing damn well how they'll be used?
I think it's entirely possible that we have far more of these mad actors running around cities big and small than we care to imagine. And it's been going for at least 20 years with the aforementioned drugs, ugly hangovers from the 1980s dance club scenes. There are a lot more of these guys out there than there are Chos (by any definition or diagnosis, he was just mad) or Kyle Huffs (who probably could've been a date-raper before he came turned to mass murder).
What the hell do you do about this kind of behavior when these guys almost never get busted? What do you do about the Chos of the world who can subsume their incipient madness just long enough to beat a psych evaluation, the school counselor or, like Huff, their twin brother? We think we can identify this kind of sickness, but I haven't seen a drop-off in mass murders lately and I haven't heard of drink-spiking going away. I am beginning to wonder about men--because it is always men--and how they turn into such fuck jobs when the vast majority of men never get anywhere close.
I am really tired of hearing women friends of mine tell me about being slipped something in a drink. Just like I am tired of freaks like Cho and Huff.
The New York Times' Alex Berenson is at it again, this time spurring an investigation by the FDA of possible misreporting of hyperglycemia caused by Zyprexa in 2000. A February 2000 document reported that patients in clincial trials who took Zyprexa were three and one-half times more likely to develop high blood sugar as patients who did not take the drug. Lilly later reported to the FDA that there was no difference at all. A Lilly spokesman told the paper that some patients had been improperly included in the company's data analysis and once their data was corrected they submitted their data to the FDA. The FDA is looking into the matter, but has reached no decision on what action, if any, to take.
If I had time to go through my notes on the Zyprexa documents tonight, I'd point you right to the memo itself. I will make it available as soon as I figure out exactly what document Berenson is referring to.
UPDATE: The document in question is this one. In addition, CL Psych has a good post on this matter.
As I guessed last week, the Cho story will be with us for a while because it is chock full of implications and will be a whipping boy for ideologues of every stripe for months to come. Much as the Rebecca Riley story has become. Much as the Zyprexa story should have become. And, yes, these stories are deeply-interconnected. For now, here's a sampling of commentary on the Net on the Cho shooting.
Pete Earley, author of Crazy, had a sane suggestion in an op-ed in yesterday's Washington Post: there should be a patient (consumer) on the panel looking into the Virginia Tech massacre. I agree. He suggests Kay Jamison.
Crime novelist/psychologist Jonathan Kellerman opines in the Wall Street Journal that commitment laws should be tightened. He implies, too, that anyone with a flash of psychosis should be institutionalized. I will return to Kellerman's essay in a day or two because the issues he raises are at the heart of the Cho case and of mental health treatment in America. (In fact, it's this whole question that has been hanging heavy on me ever since the shooting, knowing that once again ugly arguments would be made, opponents would oppose, legislatures would legislate and anyone with a mental illness, regardless of how good a social actor they are, would become a suspect.)
Reason's liberty lovin' Hit & Run blog does a nice short takedown of Kellerman from an intellectual standpoint. The comments thread is lengthy and worth reading. (Side note: Reason, a libertarian magazine, is one of the few well-known publications in the country to consistently take mental health issues and human liberties seriously.)
The conservative forces in the mental health world are having a field day with the Cho shooting. Leading the pack is Fuller Torrey's Treatment Advocacy Center, which has several recent posts on the matter, so go skim 'em. The oft-allied with TAC family wing of the mental health movement are marching pretty much in lockstep, making the point that family members--not doctors--should be able to say when someone is psychotic and their opinion on the matter would become the basis for involuntary commitment. TAC talks this way and so too, at times, does NAMI. Jennifer Roback Morse has several posts from this perspective, so just go here and scroll away.
Neurotransmission has a lengthy post on Cho's immigrant status and how the author has seen that play out in a school in the SF Bay Area. "The elephant in the room remains the psychopathological nature of a society riven by racial and economic inequities." I appreciate the point, even if I think it might be leading us away from appropriate questions of how do we identify the Chos (and Kyle Huffs) of our land and what do we do with them then.
The Last Psychiatrist has his usual contrarian (and semi-racy) take on Cho's mental health status.
Franklin Graham, son of Billy, had some bizarre shit to say about the Cho shooting. I am tempted to call delusional, psychotic and out of contact with reality his assertion that Cho's lack of belief in God was at the heart of the massacre and that FG needs some Zyprexa with the good book. But, nah, easy target.
Treatment Online on the tricky legal issues around mentally ill college students.
NBC News continues to defend its decision to air the Cho pics and videos. As a journalist, I agree. As a patient, I think NBC has done more to increase discrimination against the mentally ill in this country in one fell swoop than Fuller Torrey has in his entire career. NBC owes it to the millions of Americans with a mental illness to provide a broader picture of how people with mental illness actually function in our society. I say that as a journalist, or soon-to-be former journalist.
The folks at Psych Data pound the pulpit that meds caused Cho's rampage. To date, there is no evidence to support or refute this type of speculation. It'd be great if everyone could just chill on this question until all the evidence is in.
Pistol Pete at Necessary Therapy has some reflections on bipolar disorder in light of the shooting.
Autism Bulletin takes a swing at the Cho-had-autism theory. Or Asperger's or whatever.
Therapy Doc considers the theory that Cho was a demented narcissist that's being pushed by Time, and discards it in favor of schizophrenia. I am still not buying the schizophrenia dx.
Vaguely interesting stuff from The Blue Voice from a criminal justice perspective.
A patient reflects on his time in psych units and how the system worked for him.
I'm having to do a lot of thinking about my life and my future lately. My back is to the wall, sadly: my rent just went up 10 percent which is something I fear I cannot absorb. I am unemployed and know what it's like to feel fear when you slide your debit card into the reader at the grocery store. The media job market in Seattle is a disaster. It's just as bad elsewhere: The Chicago Tribune and Los Angeles Times are on the verge of announcing major job cuts. There have been sizable cuts at almost every major paper in the country. Magazines do almost all of their work through freelancers at pay rates that haven't changed since the 1980s. I am far from the only journalist whom this is affecting.
It's been like this in the print media world for several years now (since maybe 2001) and it does not appear that the bleeding will ever stop. You can thank Google and Craigslist, among others, for this state of affairs. Meanwhile, complete yahoos have taken over papers like The Village Voice, running many good journalists out of jobs in the bargain. I was one of them. It appears, sadly, that there are just no more jobs out there for mid-career types such as myself. We are either replaceable by cheaper 20somethings or not cool enough to dig whatever new vibe an inexperienced 30-year-old editor thinks is crucial.
Most discouraging to me is that I have made a few substantial article pitches, as they are called, on mental health issues to major publications. In each case, I have not even received a reply much less a "No, thanks." I was especially surprised that that the most progressive major magazine left in this country was among those. If they don't care about this shit, then I can assure you no one does.
What's more, I finished a book proposal in January. I sent it to a bigshot agent in NYC whom an author I know had put me together with. After six weeks of waiting, I finally contacted the agent to see if he'd even read my proposal. He hadn't and so I took it away from him. The proposal has now been at another agent for four weeks and I have heard nothing either.
Compounding matters, the cost of decent housing in Seattle has gotten out of control and will only get worse. There are a lot of rich people and well-off high-tech people moving into town and forcing out the middle and lower classes. In a few years, Seattle will go the way of most of California and become a land of elites--and people who managed to buy a home decades ago--and the struggling classes who serve them. I suspect that I won't be around to see that, but having watched it in California I know it won't be pretty.
The long and the short of it is that I am seriously considering a move (to where I know not), a career change (to what I know not) and ditching this blog. I have worked very hard on this blog for 19 months (as many as 200 hours a month at one point), but I don't think that I am having any impact whatsoever and I have to be an adult and face facts. The pharma companies, Fuller Torreys and NAMIs of the world own this game and the media, such as it is, largely buys into their views on mental health in America. That's OK, I guess. Everyone has to find their own truths in life and I wish everyone a bunch of luck figuring out what the truth is under those circumstances. I've spent the better part of six months since leaving my old job trying to make this all work and stitch together a living and a future--from journalism in whatever form--and it just doesn't look like it's going to work out. I am in need of a lucky break and while my experience is that such things usually happen when you work very hard, I'm afraid that's not the case. I am tired of swimming upstream.
So, yeah, I am giving a lot of thought to things. And I am not sure I like where my thinking is going. Nothing is decided, nothing is certain, but it is all something I have to think through. That's reality. So there you have it.
BTW, I know many of you will want to suggest jobs I ought to do, etc. I appreciate your sentiments in advance, but I can assure you that the money has gone out of the print media world, television is for fools, and suggesting that I do a public relations job is about like me suggesting that you go become a prostitute.
Or writes. Yes, the most famous psychiatrist in America has an op-ed in the New York Post--apparently, no good paper would have him--in which he asserts that the mentally ill commit five percent of all murders in the US, that Cho was schizophrenic and so on. Pretty typical stuff, which even includes misdating Cho's massacre.
Over the weekend, media accounts began to suggest that the Virginia Tech shooter had been diagnosed with autism and others have strongly stated that he had Asperger's Syndrome--an autism spectrum disorder--and his traits sure do seem to fit in with AS. Except for the violence, as this doctor notes. Hugh Hewitt, one of the most read bloggers in politics, continues to attack NBC for airing Cho's videos and pictures while Hewitt himself has continued to insist, citing an NYU doc, that Cho was schizophrenic. Nice try, Hugh, but no.
I almost put the Asperger's dx out there last week, but wanted to hold off and see what surfaced. I suppose you could account for his paranoia with a paranoia NOS diagnosis. Aspies meets paranoia. Whatever. It'll do until we know more. Or less. (A lot of discussion of the autism/Aspie aspects of this here. The AS Wikipedia entry is here. Cho's Wikipedia entry is here.)
Whatever he was, I think Cho was a walking personality disorder--"a perfect storm" of psychological issues, said one expert--and it's stunning to me that we've heard no accounts of high school teachers, for example, who tried to get to him. His case represents one of the largest dropped balls I've heard about in ages.
Cho's Korean relatives' accounts of his childhood and his parents' anguish is almost too much to read. His mother used to pray that God would transform her child. I feel sorry for his parents and sister. Hell, I feel sorry for Cho, too. I wonder if he ever realized what monster was at work in his soul. Someone must've.
I mean, no one got to this guy, ever? No one tried? And he managed to keep it all afloat until he washed up at a psych hospital in December 2005? Could he not turn up as a problem before because he was bright enough to get into college? Or were his parents and teachers shielding him? To lay his actions on the mental health system that had a crack at him in 2005 is a bit much. I bet there were a few episodes where the red flags went up well before the deranged plays and his overnight in a psych hospital.
I am stressing this because it is this case that will become Example A for whatever actions the Virginia legislature eventually takes, for how campus policies are changed around the country and for how millions of Americans view anyone with a mental illness or a paranoid personality. It will likely shape policy and laws in other states as well, particularly when it comes to gun ownership by anyone hospitalized for a mental illness, however briefly, or even diagnosed with a mental illness. (I have strong feelings on the subject which I will get into another day.) Don't think I am exaggerating.
If you are diagnosed with bipolar disorder and happen to have a pilot's license, you get your ticket pulled. I asked a pilot I once knew about this and he said the assumption is that crazy people will cause accidents. So I asked him to cite one example of someone with bipolar disorder who had crashed a plane into the ground, for example. He couldn't name one.
Cho's case is so extreme and the response to his actions is very heated, justifiably so. But I worry that we may see the mentally ill, especially those in college, become legislated into oblivion. You know, have their tickets pulled.
Although I have long-admired Peter Breggin for his war on SSRIs and the mental health establishment as well as Big Pharma, I think he's dipped into the corn liquor a bit much in a recent post on The Huffington Post. In his post, he makes the case that the real lessons from the Virginia Tech massacre are:
"On separate occasions, he was involuntarily hospitalized, sent for psychological evaluation, and referred to the university counseling center. Consistent with getting him more psychiatric "help," experts have also opined on how he might have benefited from medication. These are all the wrong lessons."
OK, so far. But, then, Breggin takes a snort:
"How would a police action have affected Cho? Would it have humiliated him and made him more violent? There's no way to have certainty about this, but anyone with experience dealing with threatening people knows that a good dose of "reality," a confrontation with the law, is much more of a wake up call and a deterrent than therapeutic coddling. Furthermore, involuntary psychiatric treatment is one of the more humiliating experiences in American society, and tends to make people more angry, not less."
Have another:
"Psychiatry's last resort for presumably violent people is involuntary hospitalization. Not only does it almost always lead to rapid release, it does not help the involuntary patient. Coerced treatment is not perceived or experienced as "helpful" by the recipient but as unjust bullying. If coercion accomplishes anything, it teaches the "patient" to stay far away from all providers of mental health services."
He keeps drinking like a lot of the bloggers on Huff Post, who almost make the Daily Kos diarists look rational. Breggin ends his post with a tirade against psych meds. I partly agree with him on his points, but the Cho case is so far not a justification to say much of anything about meds. We have no idea if he was on any in the recent past. Maybe yes, maybe no. Wait and see.
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The mental health system is broken and since we can't fix that then we must have gun restrictions (which we already have). A backwards argument by Barbara Ehrenreich, a brilliant writer but sometimes a lame thinker. So of course it's on the Huffington Post. Barbara does say some smart things about how absurd most diagnosing is these days.
A whole host of mental health bloggers take on the Virginia Tech massacre. Liz Spikol. Writhe Safely. Bipolar Chicks Blogging. Soulful Sepulcher. And an awesome post by Marissa at Depression Introspection.
Aussie docs discover that most bipolars are high functioning. Gasp! Really? I'll inform the Harvard medicate-em-to-death mafia at once. (Via Mercurial Mind.)
Former NY Rangers cheerleader is sex-crazed and bipolar. So say attorneys in a legal case, alleging that hypersexuality is a hallmark of bipolar disorder. And this is a problem how? BTW, there were no cheerleaders in hockey when I played, so when did this change?
Neurophilosphy on the 64th anniversary of LSD. Drop in, tune inn, tune out and drop out. (Via Mind Hacks.)
Psychology one of 10 most satisfying jobs in America. No word on where psychiatry or pharma rep rank. Authors listed as number four. Yes, but only when we actually make money.
I forgot to mention in my earlier posts on CNN's coverage that Andy Behrman, aka Electroboy, did a fine job on Anderson Cooper last night. In the brief time he was given, he mostly spoke of how lame/overwhelmed mental health facilities are on college campuses. But he tried to go meta on Cooper:
"Mental illness is still taboo."
And that's kind of a problem. Funny how Andy got like two minutes while much more time was alloted to docs talking out their asses and Pete Earley. Isn't it odd how patients are often just added to these programs to offer the appearance of fairness without allowing them to add real depth to the conversation? Or maybe it's not odd at all. After all, we are crazy and scary.
CNN and NBC, the two networks I happened to watch last night, had loads of coverage of the Virginia Tech massacre last night. Most of the coverage is not worth recounting--let's just say there are a lot of stupid assumptions among journalists about the commitment process--although CNN did a generally OK job even though they steered far from getting after any of the subtleties of these complex issues. I mean it's kind of funny that the fact that antipsychotics like Zyprexa kill and/or mess up patients clearly hovers in the background of all treatment questions, but all you'd hear on CNN were psychiatrists talking about how psychotic and paranoid Cho Seung Hui--that guy--was and how treatment works. (I guess I must've read the CATIE study upside down.)
One buffoon on the Larry King Show went so far as to say that people with psychosis were a "homeland security issue." No, I am not joking.
What's striking is how hard the media was working to have some kind of diagnosis to attach to Cho. And how some academics are issuing press releases to tout their pet theories (Cho as a child abuse victim in one example, which I almost buy). In fact, the New York Times even ran an article about the reluctance of some in the mental health world to do a post-mortem diagnosis. Yep, the cognitive dissonance out there is very loud.
As much as I don't like getting into this game myself, I have to keep in mind that I am an advocate. So here goes my spin on the diagnosis wheel.
I think depression can be safely excluded as a diagnosis. Bipolar disorder, too. Anxiety. ADHD. Personality disorders? Most of them, except maybe narcissism and social disorders. What people keep coming back to is "paranoid psychosis," which means they are trying to say schizophrenia but they cannot because Cho's behavior is a bit too rational--while being wildly delusional--to be straight-up schizophrenia. Besides, I think everyone in the mental health world is well aware that schizophrenics have enough discrimination to contend with without having someone like Cho added to the sick assumptions people make about them. As for prodomal schizophrenia, um, I don't buy it either but cannot wait to see researchers and the TAC crowd try to turn this incident into the war cry for more preventitive medication of teens "believed"--by what objective standard?--to have prodomal psychosis.
As sick, messed up and deluded as Cho's actions and rants were, there is an odd rationalism to them. I am leaning towards some kind of psychotic PTSD sort of hybrid. That's my guess right now. The guy was clearly a very wounded creature--regardless of the real or imagined cause--and ready to fight everyone on the planet including his imagined enemies. As The Last Psychiatrist guessed over the last few days, there is some kind of movie character/gamer thing going on in his rants. It's like Cho is acting out a role, especially when you look at his poses, looks at his clothes and hair and listen to his rants, which sound like the kind of boilerplate rage you see in bad movies.
In other words, something weird and fucked up happened to this guy. His grandmother reported that something was off with Cho even when he was a child. He wouldn't communicate even with his closest family members--and he got into college how?--or neighbors he'd seen for years. He was reportedly bullied at high school and taunted over his accent and distance from other kids. He'd get called on in class and just hang his head. That's really sad.
A couple of Asian-American friends of mine encouraged me to look into how his immigrant experiences might have shaped him. I'd like to do that sometime. We all ought to be asking a lot of questions about that and other things I've listed above.
But we also ought to remember the mass murder in Seattle a year ago, when Kyle Huff shot down six people he didn't even know at a party and then turned his shotgun on himself. Aside from the taped statements and photographs, the cases have some similarities. Mass murder with lots of weapons and rounds involved. Someone quietly carrying a wound who melts down over time, keeps it more or less hidden, and then plans and executes a shocking murder. (Huff would've killed at least six more people if a lone cop had shown up and, blowing off his training, gotten out of his car alone to confront Huff.) Cho cooly went to a post office and shipped his manifesto to NBC News before setting off to murder another 30 people. Huff walked out of a party where people had been friendly to the loner for hours, walked down the street to his truck, got his weapons and on his way back to the house, stopped to spray paint the sidewalk thrice with the message "NOW." He was six-five and had to get on his hands and knees to do it. Then he went and did what he did, shouting, "There's enough here for everyone" as he unloaded on a bunch of ravers and hippies about whom he'd developed some delusional ideas (he's written a short manifesto which was later pulled from a dumpster). He'd even stalked this group of people at other parties for a few weeks.
Cho and Huff are kissing cousins. Hopefully in Hell.
As they will in Virginia, authorities ginned up a special panel to look into the act. They found nothing. Huff had managed to keep his wounds and his plan secret from his twin brother with whom he lived (that's deceit). They determined that he was a paranoid sociopath if I recall properly. When the police went through Huff's hard drive they found nothing. He had erased it.
They may find more with Cho's effects, but probably no deeper answers.
Last night on CNN's Anderson Cooper 360 Pete Earley, author of Crazy, made an appearance to answer some general questions about mental health treatment and access to the same. Earley's book makes the argument that we are jailing the mentally ill instead of treating them, which is true, and that all that's needed is for the stigma to go away and for funding to be found for treatment programs and psych beds and all will be well again. That's the essential argument of the Treatment Advocacy Center and NAMI, both of whom Earley is ideologically aligned with (and whom he leans on in his reporting), and it's the biggest half-cure I have heard of. I've spent too much time going into this elsewhere to repeat myself here. Except I will.
On the show, Earley said, "This is a lifetime illness." He referred to his son, who has bipolar disorder.
OK, where are the studies of the lifetime course of bipolar disorder? Where are the replicated studies proving that bipolar disorder, or depression for that matter, are lifetime and forever illnesses? I don't know of any actual scientific studies on this point--if others do, pass them along--but I know that researchers, advocates, clinicians, families and patients all say it.
But absent such studies what Earley and others are saying is a political statement, a statement of collective social belief and religion. When I meet someone who has been bipolar for 80 years and has been bipolar the whole time, then I will believe it a bit more. Until then, no dice.
Earley also said, "People are not being treated....It's a lack of funding."
That's not true. People are taking meds at a rate never seen before in human history. Not everyone who has issues is of course, but the prevalence of people with psych diagnoses receiving treatment is much higher than it once was.
A lack of funding? True, that's been a constant problem and is the hallmark of any social service system. But what's lacking our mental health system isn't a lack of money so much as it is a lack of treatments that work, that are effective in the long term not in the immediate crisis, and do not wreck patients cognitively and physically in the deal.
When we get there, then we can talk about funding and people getting treatment. Until we get there, we are really talking in half-cures, ones that benefit researchers, advocates, clinicians, families and authors like Earley, but are maybe of half-benefit only for far too many patients.
Andy Behrman, aka Electroboy, will be on CNN's 360 with Anderson Cooper this evening. He'll be discussing mental health issues in light of the Virginia massacre. The show airs at 10 p.m. EDT and 7 p.m. PDT and repeats in the early morning as well. When Andy was on Cooper's program in 2005, they gave him such a short period of time that he couldn't offer an intelligent response to questions. Hopefully, things will go differently this time.
The fine folks at the Treatment Advocacy Center are back with another predictable post on the Virginia massacre which I will respond to another time. Opportunism abounds at TAC.
For the morbid among you here's that guy's not very revealing mental health evaluation from December 2005.
The Poynter Institute--a media think tank--has a good item encouraging the media to be very careful in how in portrays people with depression. It operates on the assumption that the Virginia shooter had depression as opposed to something else. I hope that they extend that sort of sobreity to any mental illness once there is some more clarity on what diagnosis fit that guy.
There does seem to be a consensus developing in the blogosphere that that guy may have had schizophrenia. I am still not sure of that, but here's someone making a fairly intelligent case for promdomal schizophrenia. I'm not even sure if that's a diagnosis. As deranged as that guy may appear, I am not convinced right now that that makes him psychotic clinically.
The Last Psychiatrist offers his criticism of those looking into the DSM for answer about that guy. He says you may get better ideas from figuring out what movies that guy was try to imitate. I tend to agree. He has another post answering a reader's suggestion on a possible link between schizophrenia and children of dry cleaners. That guy's parents reportedly owned a dry cleaning business.
Psych Central has a post on resources how to deal with the aftermath.
CL Psych is back from his time out and has so many excellent posts up today that you should just go to his site.
It's not rained here the last couple of evenings, so I have taken time off to enjoy the mere fact that the days are longer and that it's not raining. I've been reflecting as well on the Virginia Tech shooter, and a lot of the bad memories of the mass murder in my neighborhood last year have floated to the surface. They are minor in comparison to what others are going through, of course, but the voodoo does slow down the mind in ways I cannot get at.
Some aspects of that guy's mental health history are beginning to emerge: he was seen at a hospital, committed by a judge, kept overnight and was released the next day after a doctor deemed that he could be let out into outpatient treatment. Those are the bare facts on that end. Obviously people were scared of him on the Virginia Tech campus and by now I assume most of you have seen out takes of the video clips and pictures he sent to NBC News and have read his deranged statements.
Some bloggers have declared him a classic paranoid schizophrenic. That's possible, but I don't see the evidence for it because a) that guy was released from a hospital after a brief stay and, from what I have read, was not given a diagnosis (that might change as more information comes to light) and it doesn't strike me as too likely that a hospital-based psych doc would release a paranoid schizophrenic so quickly; and, b) almost every schizophrenic I've seen or read about has been too deranged and/or cognitively-shattered to pull off all the computer tricks that guy did (yes, they can write manifestos as did the Una Bomber). But perhaps I am wrong on these points.
John Grohol at Psych Central has offered some smart thoughts about society's need to grapple for the why of that guy:
"Whether or not the person who perpetrated the shootings has an illness or specific motivations doesn’t explain a tragedy of this nature. Honestly, nothing can. Most people deal with human tragedies throughout their lives and most people do not go on shooting rampages. A failed exam? A break-up with a girlfriend? Angry at the school for not letting him or her in? Even if there was such a “reason,” what would it explain? People normally don’t take such extreme criminal actions when confronted with a big life disappointment."
Grohol has also picked up on the annoying tendency of some psychiatrists and psychologists to encourage the media's dissection of that guy. All the same, I have heard and read a couple of psych docs describing that guy as being a narcissist. I'll buy that for the moment, until we know a whole lot more.
The Last Psychiatrist suggests that that guy's Ismail Ax handle may have something to do with gaming. Interesting.
NAMI put out a press release: "Despite media reports, Cho Seung Hui, the shooter in the tragedy, may not actually have had a serious mental illness relative to other diagnoses." Meaning that guy may not have been schizophrenic. We'll see.
TAC has some predictable thoughts.
I hope to be back soon with some other thoughts and some other news. After all, the doctor who was a co-author of the infamous Paxil/Seroxat Study 329 is at it again. This time, he co-authored the much repeated study in the media that just appeared in JAMA asserting that SSRIs are just fine for kids. But I'll get to that later.
As I suspected, we have a stalker type on our hands, according to this AP story.
"The gunman blamed for the deadliest shooting in modern U.S. history had previously been accused of stalking two female students at Virginia Tech and had been taken to a mental health facility in 2005 after an acquaintance worried he might be suicidal, police said today."
And here's a long bit from his former Lit profs and classmates:
"Professors and classmates were alarmed by his class writings — pages filled with twisted, violence-drenched writing."It was not bad poetry. It was intimidating," poet Nikki Giovanni, one of his professors, told CNN today.
"I know we're talking about a youngster, but troubled youngsters get drunk and jump off buildings," she said. "There was something mean about this boy. It was the meanness — I've taught troubled youngsters and crazy people — it was the meanness that bothered me. It was a really mean streak."
Giovanni said her students were so unnerved by Cho's behavior, including taking pictures of them with his cell phone, that some stopped coming to class and she had security check on her room. She eventually had him taken out of her class, saying she would quit if he wasn't removed.
Lucinda Roy, a co-director of creative writing at Virginia Tech, said she tutored Cho after that.
"He was so distant and so lonely," she told ABC's "Good Morning America" today. "It was almost like talking to a hole, as though he wasn't there most of the time. He wore sunglasses and his hat very low so it was hard to see his face."
Roy also described using a code word with her assistant to call police if she ever felt threatened by Cho, but she said she never used it.
Cho's writing was so disturbing, though, he was referred to the university's counseling service, said Carolyn Rude, chairwoman of the university's English department.
In screenplays Cho wrote for a class last fall, characters throw hammers and attack with chainsaws, said a student who attended Virginia Tech last fall. In another, Cho concocted a tale of students who fantasize about stalking and killing a teacher who sexually molested them.
"When we read Cho's plays, it was like something out of a nightmare," former classmate Ian MacFarlane, now an AOL employee, wrote in a blog posted on an AOL Web site.
"The plays had really twisted, macabre violence that used weapons I wouldn't have even thought of."
He said he and other students 'were talking to each other with serious worry about whether he could be a school shooter.'"
Mean mass murderers such as that guy don't happen overnight and I don't think they happen over a couple of years of college either (they can, but let's be real). Former neighbors in his hometown have described that guy as being just as quiet and surreal well before he went to college.
I am going to go out a limb here. Something happened to that guy long ago, something really awful that shaped that guy's character and personality and, eventually, pushed him into madness. I wonder if we'll ever know what it was.
I had planned to do a longish post on the Virginia Tech shooter--that guy, as I am calling him--but I am tired and would like to see what other new details trickle in. Clearly, that guy had some very serious issues, his play writing disturbed professors (who've seen it all, I bet), his character unsettled roommates and so on. The New York Times has a decent round up of what's known as of now.
It's clear now that that guy was on meds of some kind or had been in recent months. There's no news on precisely what he took. It's not clear what condition he was being treated for, although the descriptions I have read of his silent ways don't scream bipolar disorder or schizophrenia--both disorders are connected to much more noisome behavior and more of a character (or maybe I am wrong). That guy comes off like a stone wall who talked to no one--I knew guys like this in college--so it'll be interesting to see what comes out on what his diagnosis was, what kind of care he had, what kind of meds he took and so on.
I am going to leave it at that for the moment.
Not a lot to pass along today. Except to note that some more solid details are beginning to emerge around the VT massacre shooter. The things that jump out at me so far are that he'd been on an anti-depressant at some point--it's not clear how recently--and that he had been to the counseling center on campus. Again, not sure how recently. More to come I am sure.
Brandweek NRx has a couple of items on the AstraZeneca marketing dust up. It's fascinating stuff. Pharmalot has more too on an AZ exec's talk to college students. The accusations of off-label marketing are flying around. Former pharma exec Peter Rost has that. This begins to sound like it will be the scandal that keeps on giving.
All for now.
I did the best job I could of ignoring the saturation coverage of the massacre at Virginia Tech yesterday. The whole thing is too much on so many levels and I really don't have words for it. Except for this: There were news reports last night that the shooter, still officially unidentified, may have been a jilted lover who went to kill the girl who did him wrong, shot her and the resident assistant to death, and then went on the biggest shooting spree in American history (and not with an assault rifle, but with handguns, so he had this planned well in advance).
Over a romance gone wrong. The whole thing will be a murder-suicide on an unthinkable scale. Why the hell do some people, who probably otherwise pass for normal, come unhinged like this over love? We had a mass murder in my neighborhood a year ago--six people, including two teens, murdered at an after hours party and the gunman killed himself when the cops showed up--committed by a loner who didn't fit in and seemed to be set off, according to some theories, by not getting anywhere with women and then bumping into the free-love rave community. And going over the edge. I guess we never know the answers to this kind of shit.
BTW, the Seattle Times recently ran a fascinating article about the cop who was first on the scene at our local killing field. Worth reading because cops never talk about how it plays out for them. Word has it the suicide-by-cop thing also plays out pretty rough for the cops involved.
There have been a couple of good, longish articles in the media recently about Iraq War veterans running afoul of the military's bizarre mental health system. In both, the soldiers suffer from PTSD and a host of other psychological ailments. In both cases, they are getting screwed over. No surprise there. In one case, the vet is a woman who was raped by fellow soldiers in Iraq. (I cannot even wrap my mind around that. It's simply absurd that guys would do that.) Anyway, read the articles.
Another concern is that we are in a very different kind of war in Iraq than we are accustomed to--a largely urban guerilla war with IEDs around every corner--and the military is doing a shitty job of addressing post-combat PTSD and the like. A couple of years ago, I interviewed the police chief of a small town south of Seattle for an article I was pondering doing about car theft rings and how they transport stolen vehicles out of state within hours of stealing them. This town backs up on Fort Lewis, the largest Army base in the country, and is right on I-5 along which many of said vehicles make their way to California. We were basically bullshitting about things his cops run into on the road, especially enforcing traffic laws on I-5.
Turns out one the department's biggest issues was with Iraq vets who they pulled over for speeding. The chief told me that they will often get out of their cars--a big no-no at a traffic stop--and be ready to go to fists with the cop. Over a damn speeding ticket.
"Those guys are coming back in rough shape," the chief said.
No kidding. The first article I linked to above goes into the kind of shoddy treatment soldiers with psych issues are getting at Fort Lewis. Not that it's so spectacular in the civilian world. But it really galls me that we send young men--and it's still mostly men--off to war, ask them to do crazy shit, tell them they are heroes and that we'll take care of them, then when they have bad outcomes from doing and seeing crazy shit, we blow them off. These soldiers and marines get dogged by what they dealt with for years. Just ask my dad, who is a combat vet.
This sort of business is just one of many reasons I don't hold the federal government in high esteem.
Eli Lilly reports sparkling financials and increased revenue from Zyprexa, although that's mostly related to increased prices. Cymbalta sales way up. Still, company profits were off 39 percent due to the Icos acquisition. Not clear if the $500 million Zyprexa settlement announced in January is reflected in Q1 financials.
CL Psych on Forest Labs' attempt to kill citalopram (Celexa) sales in favor of Lexapro, its still-patented Celexa knock off. Forest makes both Celexa and Lexapro. Strange shit.
The Last Psychiatrist makes some points about the politics of shifting from classic mood stabilizers to atypicals as "mood stabilizers."
News Flash: The fine folks at the Treatment Advocacy Center and I agree on something. Namely, that psych patients should be asked if they own firearms. Where TAC and I disagree is that such should be the case in commitment situations or where people are clearly psychotic but under some form of home care. Otherwise, trying to get weapons away from people absent a threat to self or community means you are denying them their constitutional rights to self-protection. I know such talk will make some readers uncomfy, but rights apply to everyone equally or they apply to no one.
An interview with a researcher on the cats cause schizophrenia who-ha.
Kansas Sunflower continues to have Seroquel issues. Sounds like the drug isn't working well. Surprise.
Twenty-one people killed in a shooting rampage at Virginia Tech. Has also been reported at 31 people. Dear God, what the hell is wrong with people?
Some Net heads want to scrap the current Net and start over. They have a point.
Over the last few years, psychiatrists have been pushing Lithium as an anti-suicide technology, for lack of a better term, in bipolar disorder. This is a well-studied bit of territory and I mostly accept researchers conclusions on this point. Assuming someone responds to Lithium in the first place.
Interestingly, a study is now out proclaiming that dear old Li works the same trick in major depression.
"The overall rate of suicidal acts was 1.48 per cent annually among those not given lithium compared with 0.17 per cent per year among those treated with lithium--an 88.5 per cent reduction in risk."
Pretty dramatic data and not surprising at all. Although it ought to be amusing to know what kind of responses docs get when they try to put unipolars on a med classically employed in bipolar disorder. "So, you mean I am fucking nuts then?"
I am becoming warmer to the notion that bipolar disorder and major depression reside on the same continuum. Lithium is far from a clean medication, but it's cleaner than anti-depressants and atypicals. I suppose the next point on which I'd like to see data--but am too lazy to go digging!--is on Lithium's effectiveness in treating major depression long-term as a monotherapy. We have some decent evidence of limited anti-depressant qualities in studies of bipolar disorder and Lithium, so you've just got to wonder. Especially, if it's all part of a continuum.
As an aside, the patients in this study who did not receive Lithium were likely on an anti-depressant of some kind. (I don't have access to the particular journal, but anyone who can login to JCP feel free to pass along the paper.) So if Lithium can outperform anti-depressants in addressing suicidality, then we are investing so much money in SSRIs and SSNRIs because why?
Aside #2: I have never heard of Lithium inducing suicides and or suicidal ideation. Anyone know anything to the contrary?
Thanks to all of you who commented over the weekend following my Friday query about where the readers went. I guess Easter Break/Spring Break does get staggered in different weeks around the country. To explain one thing, I do the Media Madness thing--anyone got a better name for it yet? Please--because I want to pass along things I don't have the time to say anything intelligent or dumb about. And it's also a sensible way to help other bloggers in the mental health world get attention for their own work and show up higher in Google searches until we all end up having as much say in the "conversation" about mental health as does Big Pharma. Google is a function of links and hits and the more the merrier is what a friend of mine who works at Google told me. Before refusing to answer any further questions about the company's search and ranking algorithms.
On another front, yes, I know I have written about the Zyprexa thing to death and I am sure that bores some people. But what I think some people fail to appreciate is that there has never been quite such a blow up around a psych med before that was accompanied by a huge volume of documents (Prozac and Paxil come closest in this respect)--and someone has to connect the dots on this crap every step of the way. Why? Because a decade from now, this will all happen again with another med and all this Zyprexa information will be right here on the Internet so that some future researcher or reporter can page through it all without having to do a ton of original reporting on their own. I look upon it all as a public service. Seriously. And a free one at that.
Finally, I have been thinking for quite some time about taking on other social issues with this here blog. Mainly involving men and American culture and the place of men in American culture in a way that has nothing to do with lad mags and other men's mags. I've got to tell you that the expectations placed on men these days are very confusing--we are supposed to be hunter-gatherers and compassionate earth-sharers at the same time, among many other things, to use one example--and we have to find out where we fit in a world where straight men are often spoken of as veritable oppressors (seriously) and most criticisms leveled at men by feminist writers go unanswered. I have watched enough men either fuck up or crumple under the changes to stay silent about it too long.
Why me? Go do a Technorati search for blogs that tag posts "men" or "men's issues" and you'll see that it's mostly blogs by feminists and gay men. Which isn't very representative of straight men. And so I'll likely poke at some of these issues in the next few weeks and see where it takes things. Besides, it all nicely circles back around to psychological well-being and mental health anyway. And I like the idea, even if it'll just be an experiment.
The whole AZ sales manager who sent out a memo saying cancer docs' offices were like buckets of cash dust-up (the memo later leaked out) has now led, potentially at any rate, to a top exec resigning and a steaming pile of bad press. Over at Brandweek NRx, there is news that AZ may have been involved in off-label marketing. And Pharmalot has more on a group of AZ employees who've gone whistle blower on the company.
Although none of this involves Seroquel, you have to wonder what kind of evidence of similar practices and attitudes Congressional investigators will find in the documents they requested. My hunch is a lot. So if this current scandal is making AZ nervous, just wait until they get called to a Congressional hearing.
Stay tuned.
In other news, I've noticed a significant drop off in traffic and comments the last couple of weeks. Not sure why. One regular reader speculates that it's because I haven't been doing long, windy posts the last two weeks--hey, I've been busy!--or that it's connected to a post I did a couple of weeks ago wherein I admitted to drinking some whiskey and smoking a wee bit of pot as an experimental "break the cycle" for a looming bout of depression. And that that alone may have driven oodles of people away.
I haven't the foggiest what's at work, but would appreciate hearing others' speculation.
Yet another class action suit on behalf of Eli Lilly shareholders has been announced. That makes two or three now--frankly, I am tired of counting--and there are the usual accusations of fraudulent behavior, etc.
Who ever thought those secret documents work uncork so much trouble for Lilly? It will be interesting to see how this all plays out.
If you've stopped by, you've noticed that there are no new posts for today. Nothing freaky going on. Outside work crashing into frustrations with life and the universe and all the time I put into this blog. That's my story and I am sticking with it.
Many things to link to today.
First, the New Yorks Times' Bob Herbert on a misbehaving six-year-old in Florida being carted off to jail by the police. The girl was having outbursts in class and in an office. She happens to be African-American. Very reminiscent of another case of a black girl who acted out in school and was arrested last year. Also an elementary school kid. This is bizarre and I'll say more about it tomorrow. (Via CL Psych.)
CL Psych also picks up on The Last Psychiatrist's recent post on atypicals replacing anti-depressants. Go the end of CL's post for a brief history of diagnoses and meds. I wrote about this last week. I continue to be fascinated by the unjustified emergence of atypicals for long-term use in mainstream culture. Mother's little helper. Psych Central has a slightly different take on The Last's posting.
Also, Psych Central has thoughts about the AstraZeneca sales manager being blunt about how sales reps should view doctors' offices.
An op-ed in the New York Times claiming that the mental health parity bill in Congress will discourage use of evidence-based treatments. Advocates for evidence-based treatments that have been shown to work. What evidence base would that be? Pharma-sponsored clinical trials? CATIE, STAR*D and STEP-BD? The corrupt Texas Medication Algorithm Project?
Pharmalot on Big Pharma's bad reputation with the public.
Man jumps off bridge in Seattle, knocks out power to neighborhood.
One of the Bipolar Chicks Blogging crew writes of a nasty bout of depression.
A blogger outs herself as having bipolar disorder. Welcome to the show.
A bipolar ditches as many meds as possible, including Cymbalta. I hope she's doing this under some form of doctor supervision.
Patient goes off meds. Will confess to doc today.
The Canadian government continues to go after the makers of True Hope. I don't know enough about Canada's drug laws to say much, but it strikes me that the True Hope people aren't saying anything more bizarre than Big Pharma does every day.
Guns in homes leads to higher rates of suicide. Apparently independent of a mental illness. Not sure I completely buy this. Will be used by anti-gun lobby.
Patient has one year of ups and downs on Cymbalta.
There was an interesting AP wire story on the Net last night about a psychosis prevention program in Portland, Maine. It's so successful, say its proponents, that it is going to be replicated at four other sites in the US. The article is here. The program's website is here.
Sadly, I don't have time to dig into this as much as I'd like, due to an outside project absorbing my brain, so I pass the above along in hopes that some of you will react to it in comments. A few things did jump out at me, however:
1. The claim that only 14 percent of program participants--teens and young adults mostly--later experienced psychosis within a year of entry in the program (where they were apparently put on smallish doses of antipsychotics in order to prevent full-blown schizophrenia) is a claim that has not been submitted to a peer-reviewed journal. Perhaps many of the other 86 percent had false positive signs of impending psychosis, for example. And what about two years later?
2. The PRIME study at Yale, which I've written about before, is conceptually similar to this program. PRIME was a failed experiment (16 percent of patients benefitted from the protocol) in my view and a substantial ethical breech. There was an interesting exchange of letters about the ethics of PRIME in the American Journal of Psychiatry.
3. The Portland project is partly underwritten by the Robert Wood Johnson Foundation. The RWJF is funded by the founders and descendants of Johnson & Johnson. J&J makes Risperdal/Invega. The foundation will also underwrite the other four other centers around the country.
4. The program's website states that "Mental illness refers to chemical changes in the brain." That statement approaches a religious statement.
5. The program's website states that "mental disorders are diagnosed in the same way as asthma, diabetes and cancer." OK, that's a lie.
6. The program's website states that "treatments of mental illness are effective 60 percent to 80 percent of the time." I guess these folks missed the CATIE, STEP-BD and STAR*D studies.
7. Take a look at the teacher's toolkit on this page.
8. NAMI is listed as a sponsor of the project.
9. Take a look at the symptoms in the pre-illness phase on this page. So was the fact that in high school I felt others didn't like me a sign of impending mental illness? Or was it a result of the fact that my family moved so much that I went to four high schools and was always the new kid and, well, sometimes kids just didn't like me?
10. As usual with these press conferences, which you can see the initial story was built around, the sponsors roll out a patient to tell how much treatment has helped them and how they wish they'd had it when they were younger. That's nice and I certainly wish this patient no ill will. But the fact that he developed schizophrenia, wound up in the hospital and on the streets, does not speak to the "psychosis prevention paradigm" in the prodrome in any way, shape or form. It's little more than political spin that the reporter should've caught.
11. The AP reporter should've been knowledgeable enough about this complicated field to at least ask about disputes in the psych world about prevention. Or his editor should've sent a more knowledgeable reporter to the press conference. As it is, the AP's coverage of this story is deeply biased.
12. Despite all of the above, I am semi-warm to the idea of prevention of mental illness. Once some genius can find symptoms that predict its onset 100 percent of the time and medications without side effects that prevent its onset 100 percent of the time, then I will be all hot for prevention. Until then, no sale. I am not about to support doctors who want to medicate a bunch of goths and punks and emo kids because they wear makeup and piercings and listen to bands which mommy and daddy and teacher don't like.
13. If you think I am being out of hand, check out what John McManamy, with whom I am often at odds on psych issues, said about the prevention paradigm on my blog last year:
"Last night, I was at a gala NAMI fundraiser in DC. BMS was picking up the tab. The Pres or VP of BMS Neuroscience [Bristol Myers Squibb] got up to say his perfunctory two or three words, which turned out to be a shameless promotion for Abilify. Among other things, he mentioned psychiatric meds in the context of prevention. He specifically used as an example of patients who have never had a heart attack taking heart meds. One guess what he was driving at?If we were talking about an illness we actually knew something about, in a population with a very high risk probability of onset, with drugs that were predictably effective and tolerable then the conversation would be a lot different."
I look forward to your comments.
Since I am tied up with other things, I am going to pass along a butt load of other reading for you all to consider, ponder and discuss.
Seroxat Sufferers busts another astroturfing advocacy group. This one in Oz.
CL Psych turns up all sorts of bizarre promo giveaways Eli Lilly has used for Zyprexa. Pocket knives, tape measures. Can a Zyprexa blood sugar monitor be far behind? Remember: Lilly Cares and has Answers That Matter.
Pharmalot on a public relations nightmare at AstraZeneca over statements made by sales manager. Funny, but the guy sounds exactly like my sales managers when I was a rep for Abbott. Interesting comments on all of this at the CafePharma board.
Lithium builds gray matter in bipolar brains. Interesting. (Via Psych Central.)
Yet another shareholder class action suit against Eli Lilly over Zyprexa. Does Lilly ever have a good news day? If so, I'd be happy to report it.
The Atlantic has an article on Japanese suicide cults. It's not online for free so if anyone has access, let me know.
A longtime advocate for the homeless reconsiders Bush's 10 Year Plan to End Homelessness. Short story: it isn't.
Seattlest links to my take on the New Yorker's bipolar child article. I appear in the post behind Bill Gates. World's richest man tops hunger artist again.
Stir Crazy on suicides and psych meds and, you guessed it, Eli Lilly.
I have zero wisdom to offer this morning--not that I ever do--as I was working on an outside project last night. But I did want to pass along a few Cymbalta comments that have cropped up again. They seem to arrive in bunches and I know some of the commenters arrive here by way of a search engine. Interesting. As before, if anyone has Cymbalta stories they'd like to share, good or bad, pass them along.
First:
"I had the night sweats and dry mouth and sweating on Cymbalta. Don't know if the forgetfulness and fog was due to meds or fibro. All of the negative info out on Cymbalta is scary. I think it made me gain weight too. I am usually pretty thin and I weigh more than I have in my whole life. Used to weigh about 128 and now am up to 142. Very upsetting to me. Can't entirely blame Cymbalta since I over the last few years I've tried lots of meds for migraine management. Supposedly, Cymbalta is weight neutral but now I wonder if true.I definitely agree with other posts that all meds have the ability to cause a wide variance of reactions to people. Just starts to make a person second-guess how great a med really is if so many people have such a strong reaction/ opinion to their experience on it. Felt ok overall taking it but didn't do what I was supposedly taking it for. Good for anxiety though. Hope my fibro muscle pain doesn't worsen once it's out of my system."
Then:
"I've finally taken the plunge, and am stopping Cymbalta. My psychiatrist told me to stop taking it cold turkey! As I've read that withdrawing from Cymbalta can rival the misery of stopping Effexor, I fought with him for the honor of tapering off the drug to reduce side effects. Today is my third day on the lowest dose, and next Saturday will be my first day without Cymbalta. I have a headache that is making it very difficult to read and think clearly. I hope this isn't just the beginning of the "fun"."
Makes sense to taper any med. And:
"My nightmare with Cymbalta happened when I tried to stop the drug cold. I was yanked off of it after it was suspected to have caused a nasty manic episode. I experience vertigo and a serious anxiety attack in the grocery store."
Now for a sad one (not that the others aren't):
"I am married to someone who started taking Cymbalta 1 1/2 mo. before our first son was born (10/06). He is an avid drinker, and despite the warnings cont'd to drink while taking Cymbalta. Since beginning this medication, my husband has turned into the most hateful, aggressive person. He wants nothing to do with me because I had to leave with our child after the police were called (by him) during his aggression one night. He is now seeing another woman and would like to get divorced. His family MD gave him this medication with no couseling involved. I understand alcohol doesn't help, but he is out of control and has no feeling of attachment what-so-ever. Does anyone have any suggestions, or have you heard of this happening? I have read some cases of mania, and it sounds like what is happening to him. He LOVES the medicine because he no longer worries about anything...including his family. Please help if you have any advice. Thank you."
Any ideas? I've heard of weird affectless behavior on SSRIs, but I haven't heard much about Cymbalta in this respect.
A mental health worker's take on The New Yorker's article on bipolar children.
The Last Psychiatrist's partly-sarcastic assessment of the end of the anti-depressant age for bipolar and the birth of antipsychotics for everything. We want Seroquel in the water supply!
Connected with that, a drop in the use of anti-depressants in kids and teens. Meanwhile, use of antipsychotics in kids has mushroomed since 2000.
Health Care Renewal on the priorities of medical schools. Follow the money. (Via CL Psych.)
A patient having problems with Cymbalta, so much so that he/she has started an online diary of his/her experiences on the drug.
Interestingly, my very old post on Cymbalta and its problems continued to get comments over the weekend. I put that post up about 10 months ago, so this tells you something. If anyone has Cymbalta stories, good or bad, pass them along. I'll post them.
Seroxat Sufferers on yet another funded-by-Big-Pharma advocacy group. This one in the UK, allegedly "bringing 'mental' into the mainstream."
Mind Hacks lists the 10 most influential psychotherapists on American psychologists. Beck and Jung make the list. Not surprisingly, Freud does not. Yet ask a lay person to name a psych doc and they invariably choose old Sigmund.
Psych Central on the biological basis for God and faith. I wonder what the Pope would say.
Speaking of which, here's Off Label on Jesus Christ's mental health. And also responding to my recent post on slouching towards recovery.
I read Jerome Groopman's April 9 article on the early-onset bipolar disorder controversy over the weekend. For those of you not in the journalism world, Groopman is an official big shot. He has an endowed chair at Harvard Medical School and has been writing for the magazine for years and is also the author of several books on medicine. That he even paid attention to the bipolar child who-ha is a big deal.
His article is pretty neutral as these things go, but you can sense moments when he's clearly got his eyebrows raised. He very clearly asserts that even amongst psychiatrists diagnosing children with bipolar disorder is a heated topic. He did speak with Dimitri Papolos, co-author of The Bipolar Child, and in my opinion Papolos looks a bit foolish. Sadly, there isn't a copy of the article online for me to link to. Apparently, Groopman puts them on his website sometime after publication. (You can read a doctor's take on the article here.)
Groopman also notes a couple of times that parents of troubled children often showed up at doctors offices clutching the Papolos' book. One prominent child psychiatrist even had to start filtering out parents who'd read the book and then dragged their child to the doctor. He points out, as well, that Papolos had tons of kids referred to him after the book came out and hardly ever failed to diagnose them with bipolar disorder.
He spends some time on the dodgy matter of available treatments and notes the recent death of Rebecca Riley.
And Groopman also touches upon how vastly influential the old BBSes and list-servs that eventually grew into CABF have been on driving the issue into the mainstream world. I think that some of these internet sites have, along with the book, led to the over-diagnosing of kids, creating a kind of hysteria around the behaviors of children that have been around for centuries. It is interesting that Groopman didn't mention that several of the people he quoted in his article sit on the board or advisory board of CABF, or that the Papoloses had a tasty falling out with CABF. That's a small point, of course.
It's an article I encourage anyone to track down and read for themselves.
A few readers have written recently to ask me why I am being so tough on the bipolar child paradigm. Some blogotators have obliquely asked as well. I don't doubt that bipolar disorder--or some childhood variant of another disorder--can exist in some cases, but I have wearied of this special pleading ("we don't have real diagnostic criteria or long-term research but trust us anyway") some insist upon for child bipolar disorder. I have laid out my frustrations at length elsewhere, but here's a summary.
The reasons for my deep skepticism and bloviations on the matter is because I think it's well-nigh impossible to accurately diagnose in kids (and the fact that a kid responds to meds doesn't make him or her bipolar, as Groopman notes). Because the treatments are very rough on patients. Because there are huge questions in my mind about the possible violation of children's bodily liberty. Because I have concerns that a lot of kids are being medicated to make their parents and schools happy. Because the research on childhood bipolar disorder is quite thin. Because there has not been a proper scientific evaluation of the long term use of psych meds in children. Because we have no idea of how any of this truly affects child development psychologically and physically. Because I don't fancy the idea of handing kids a diagnosis that translates into "psycho" or "crazy" to the public at large and having them tagged with that for life. Because too many people who advocate for the bipolar child business--and it is a business--eschew environmental factors in all of this, but are all too willing to slam kids with meds that cause big cognitive problems for adults. Because the diagnosis is now being applied to as many as two million children. Because that's simply over-the-top. Because the rhetoric around child bipolar disorder has gotten out of line. Because far too many people in the mental health world who should know better have forgotten the fallout of diagnosing millions of kids with depression and ADHD in the 1990s, which led to lots of kids being injured by stimulants and anti-depressants.
And, because, I think it's my duty as a much older bipolar to raise the level of skepticism on this paradigm in the same way that I have questioned the paradigmatic shift to using atypical antipsychotics long-term for damn near every aspect of adult bipolar disorder.
File this one under interesting. According to the Guardian, Nick Craddock, a professor at Cardiff University (where David Healy also teaches), says that many patients with bipolar disorder could benefit from medication-free treatment. Instead, treatments would focus on treating triggers of various symptoms--for example, insomnia--rather than bombing the entire brain with meds for a long period of time:
"Traditional drug regimes for people with bipolar disorder could be increasingly replaced with therapies to treat the "triggers" of manic episodes, scientists say.In the future, making "lifestyle changes", as well as learning new ways to cope with stress and having more therapy, could help some people avoid a lifetime of medication, according to Nick Craddock, a psychiatrist at Cardiff University."
Sounds like something I may have said before. It's an interesting idea intellectually, but the real world mechanics of it might be tough to pull off. It is possible though. At a minimum, it would require highly self-aware patients who are willing to get on top of symptoms before they spiral into full-syndrome episodes. That's a worthy goal, however, because as Cradock notes:
"'The problem at the moment is that diagnosis often means a prescription. There isn't enough tailoring of treatments'....Craddock, who is scientific adviser to the bipolar research charity MDF, stressed the research was not yet conclusive enough for people to risk coming off their medication, nor was there enough support available from mental health services to enable the monitoring needed to prevent someone going off the rails."
Glad to see someone out there is starting to think creatively and publicly about all of this, because we sure have a mess on our hands in treating bipolar disorder via the meds-only paradigm. But you knew that already.
I've run into yet another bipolar noting that he cannot sleep without Seroquel:
"Now, I have become a Seroquel addict meaning, I don't sleep without taking the drug. I could go 4 -5 days and probably more without sleep and that means naps too. Usually, in my case anyway all my naps are 20 minutes of interrupted hell. So, my body and my mind doesn't shut down without one 200 mg pill. I'm a legal drug addict in a sense. The most important person in my life is my pharmacist because without my drug, I don't sleep, period. So, I'm like any drug addict and I go once a month to get my refill."
Although he means "addict" in a slightly looser sense than a clinician would, I keep running into similar reports. Recently, there was similar discussion of dependency on Seroquel in order to sleep, even while feeling normal otherwise, on a MySpace group. I suspect people have either built up a kind of tolerance to the drug or might be psychologically dependent upon it. And, yes, there are reports in the clinical literature of patients running into addiction problems with the drug. Seroquel has also become a drug of abuse among pill junkies in America. None of the other atypicals share this characteristic and I think only one of the first generation antipsychotics is considered addictive (I forget which one!).
Anyone have any thoughts on this phenomenon?
After the usual delays attendant to class-action lawsuits, US District Court Jack Weinstein has lowered fees that lawyers will get from the 10,000 lawsuits settled in 2005 for about $700 million. The suits were against Eli Lilly and related to injuries suffered by patients taking Zyprexa. Since then, Lilly has settled another $500 million in claims, become the subject of two Congressional investigations, faces lawsuits by seven states with potentially more in the offing, and has also faced much bad publicity due to court documents in the 2005 case, which were later leaked to the New York Times.
The judge pegged lawyers contingency fees at anywhere from 30 percent to 37.5 percent of a patient's award, depending on the complexity of the particular case. No word on how much the lead plaintiff attorneys will see from the case.
Checks are expected to be mailed to patients who were part of the class action around June.
One annoying piece of Judge Weinstein's ruling:
"By the time all the claims are paid, attorneys' fees easily could top $100 million. Weinstein acknowledged his ruling will result in "substantial" fees being paid to "only a handful" of law firms that represent the bulk of the claimants."
I'd really like to see what level of legal work and due diligence it took to wind up with $100 million in legal fees. (Via the fabulous Ed Silverman at Pharmalot.)
In fact, almost a doubling from 1997 through 2004. Beyond the obvious, it's significant because Asians, particularly ethnic Chinese (hope I can say that about Taiwan!), are loathe to address psychological issues to the point of obsession. That's what my Chinese friends tell me at any rate.
From a report in Psychiatric Services:
"The prevalence of any psychotropic drug use increased from 7.1 percent in 1997 to 12 percent in 2004. The changes in prevalence of use of four kinds of psychotropic drugs from 1997 to 2004 were as follows: antipsychotics, 3.4 percent to 3.7 percent, although this finding was not significant; antidepressants, 2.2 percent to 4.4 percent; mood stabilizers, .6 percent to 1.3 percent; and anxiolytic-hypnotic drugs, 3 percent to 7.3 percent."
I wonder what changed in Taiwanese culture over that time period to account for such a huge increase.
A bunch of things to pass along.
CL Psych has some fascinating bits on the RU-486 treatment for depression, including a researcher with some over-the-top conflicts.
Psych Central has a great post on the best psychotherapies for bipolar disorder. In addition, Doc John says nice things about this blog. I hope my mother reads them!
Liz Spikol on the possibility of MHA (NMHA) giving an award to Rosie O'Donnell. Like Liz, I am disgusted by the idea.
Charles Donovan at MyDepressionSpace says one should not disclose a depression diagnosis to an employer or colleagues. Sadly, I agree with him. Unless it's a really humane employer. I've heard they exist!
A recently-DX'd bipolar is switching to Seroquel as her main mood stabilizer. Says it has no side effects. If only that were true.
John McManamy offers another helping of Kool-Aid on the Bipolar Child paradigm (it's all about the brain, environment means nothing!) and fails to understand the purposes of journalism and blogging, or how journalists and bloggers work. Kind of odd coming from a journalist and a blogger.
Stupid emo-band Fallout Boy raises depression awareness among college kids. Yeah, but their music will still suck. My god, what punk rock has morphed into.
Nicotine may help learning and memory. I've said it before: there is something about that molecule.
An excellent ripping of the feds' War on Medical Marijuana.
Sen. Chuck Grassley (R-Iowa), former chairman of the Senate Finance Committee and now its ranking member, has requested that Eli Lilly turn over the documents leaked to the New York Times in December. The committee has authority over Medicare and Medicaid among other federal agencies. The current chairman, Max Baucus (D-Montana) is inevitably aware that his state has now sued Eli Lilly. (Via Pharmalot.)
So now we've got two Congressional investigations a-brewin'. The news just keeps getting worse for Lilly over its handling of Zyprexa. There's so much now going on that I won't even recount it.
Stay tuned. I have a hunch this is going to get really interesting. If any of you are newbies to this site, you can view the same set of documents right here.
The April 9 edition of the magazine has an article by Jerome Groopman, MD, on the controversy around the bipolar child paradigm. It's not available online currently, so I'll share my thoughts once I get off my lazy butt and go buy a copy of the mag.
If anyone has already read it, I'd be happy to hear what you thought of the article.
In other news, I'll only have a couple of small posts for today since yesterday was a mercifully slow news day in the mental health world.
Wayne Fenton's teenaged killer admits to killing the psychiatrist. Now goes off to state hospital, judged not guilty by reason of insanity. Such a waste on every score.
Teen in Ohio busted for possession of Seroquel. Which he was apparently going to sell. Man, this abuse of Seroquel stuff is getting mighty weird. People really snort this shit? Yikes.
Brilliant young prosecutor kills himself in Florida. Yet another sad waste.
Pfizer settles with DOJ for $34.7 million over off-label marketing of human growth hormone. I'd say they got off cheap.
Pharmalot has much fun with Pfizer CEO's Newsweek. Good for Ed, since the interviewer sure didn't push the CEO very hard. Damn, that magazine is lame. (Via Brandweek NRx.)
The ever-brilliant The Last Psychiatrist on caffeine withdrawal and ADHD. (Via CL Psych.)
This is a wow. A new study is the Archives of General Psychiatry asserts that "episodes of uncomplicated depression triggered by bereavement and by other loss have similar symptom profiles and are not significantly different for 8 of 9 disorder indicators" of major depression. Which leads to loss-related depression that's diagnosed as major depression overstating the rate of major depression by 25 percent. To whit:
"About one in four people who appear to be depressed are in fact struggling with the normal mental fallout from a recent emotional blow, like a ruptured marriage, the loss of a job or the collapse of an investment, a new study suggests. To avoid unnecessary diagnoses and stigma, the standard definition of depression should be redrawn to specifically exclude such cases, the authors argue."
Implications anyone? The Times' Ben Carey has those:
"The American Psychiatric Association’s diagnostic manual does not specifically exclude people experiencing deep but normal feelings of sadness, unless they are bereaved by the death of a loved one. And an increasing number of school districts and health clinics use simple depression checklists, which do not take context into account, the authors said."'Larger and larger numbers of people are reporting symptoms on these checklists, and there’s no way to know whether we’re finding normal sadness responses or real depression,' said Jerome C. Wakefield, a professor of social work at New York University and the study’s lead author.
His co-authors were Mark F. Schmitz of Temple University, Allan V. Horwitz of Rutgers University, and Dr. Michael B. First, a psychiatrist at Columbia who edited the current version of the psychiatric association’s diagnostic manual.
The study’s findings suggest that previous estimates of the number of Americans who suffer depression at least once during their lives--more than 30 million--are about 25 percent too high.
Dr. Darrel Regier, director of research for the American Psychiatric Association, said, 'I think the concern this study raises is real, and that we do need to be very careful not to overdiagnose a normal, homeostatic response to loss and call it a disorder.'"
Man, this news is not going to go over really well with the Teen Screen people, among others, because teens experience loss and bereavement like every 15 minutes. Seriously, though, psychiatrists--the good ones at any rate--have been aware of this dynamic for many years and so have many patients. So, why are we only getting a study on the phenomenon in 2007?
Tie this in with last week's news that anti-depressants don't help folks with bipolar disorder the way psych docs have long claimed and you've got a very interesting butt kicking of the dominant psychiatric paradigm going on all of a sudden.
I also hope that those "key opinion leaders" in the psych world are asking themselves plenty of questions.
I bumped into an interesting legal article yesterday. It was mostly interesting because it's now becoming obvious that Eli Lilly may be looking at many more lawsuits by states over the company's behavior regarding Zyprexa. The news just keeps getting bad for Lilly because the plaintiffs keep lining up. It's all becoming very reminiscent of the mid-1990s when the states collectively sued Big Tobacco and brought to an end many decades of bullshit spin by tobacco companies.
Here's a rundown of where matters sit today:
"Seven states have filed Medicaid cost recovery suits against Eli Lilly over the way it promoted Zyprexa, including Louisiana, Mississippi, West Virginia and, most recently, Pennsylvania. Others are gearing up to do the same. Alaska is expected to be the first to go to trial, in an Anchorage court next year."
OK, 50 minus 7 equals 43. Yeah, if all those folks got together, you could end up with one big old Master Tobacco Settlement thingamajig, or one heck of a court trial. To get a feel for the allegations, here's a summary of the suit filed by the State of Montana last month. I have no idea what the chance is of a bunch of states going after Lilly en masse, but here's what one outside lawyer handling cases for some states told Law.com:
"Fletch Trammell of Houston plaintiffs firm Bailey Perrin Bailey said four of his state clients are preparing to sue drug manufacturers for Medicaid fraud. He declined to name them. Trammell already represents Louisiana, which sued Eli Lilly over Zyprexa in 2004, and Mississippi, which filed suit last summer. Pennsylvania sued three drug makers in February, including Eli Lilly and AstraZeneca Inc."The fundamental allegation in Trammell's cases, he said, is that the manufacturers had promoted drugs for uses other than the illnesses for which they had been approved. 'We plead these cases entirely on violation of state law,' Trammell said.
"'Legislatures take Medicaid and government fraud very seriously and there are very serious and stiff penalties,' he added. 'The damages in these cases -- particularly in the anti-psychotic drug cases -- tend to be very large because they have been, and continue to be, very widely used drugs.'"
Lilly spokeswoman Marni "I Don't Answer Bloggers' Inquiries" Lemons told Law.com that Lilly intends to "vigorously defend these cases."
I'm thinking they'll vigorously settle--and sooner rather than later as it'll limit their exposure and word has it that the company can no longer get legal liability insurance for Zyprexa--so give 'em hell Fletch. But leave them enough money to cover the Cymbalta they'll need for Public Relations Dysphoria Disorder.
In a related AP story on the investor suit against Lilly that I noted yesterday, another Lilly official spun matters thus:
"Lilly spokesman Phil Belt told The Associated Press in an e-mail that the latest lawsuit was based on news stories using 'leaked documents that were hand-picked by our adversaries to paint an inaccurate, incomplete and misleading picture of Lilly.'Belt said the documents on which the Times articles were based 'are just a tiny fraction of the more than 15 million pages of documents provided by Lilly as part of the litigation process.'
"'These selected documents, as well as the associated news stories, do not accurately portray Lilly's strategy or conduct,' he said."
If Lilly has any documents to disprove the facts contained in those documents, which are also hosted on this site, then I'd really like to see them. I'll host them on my site! But I've been making that offer for months and have gotten no response.
Anyhow, the New York Times' Alex Berenson sure caused Lilly a butt load of trouble back in December. A judge deemed his reporting on the leaked documents "reprehensible." I call it good journalism and I say Lilly's claims sound like ashes settling in the dustbin of history. Since then, Lilly has settled another $500 million in one class action lawsuit (bringing their total to $1.2 billion), become the subject of a Congressional investigation and had more states sue. As far as I know, Berenson's reporting has garnered no journalism awards, which is an oversight.
Speaking of history, it will prove that judge very wrong and maybe even a little reprehensible and that the two people who leaked out the documents were very right. And righteous, even.
BTW, the last I've heard is that Lilly's lawyers have yet to file a request for sanctions against the leakers, David Egilman and Jim Gottstein. Maybe they will, but it's been seven weeks since the judge ruled against the pair, both of whom are appealing the judge's ruling in a federal court of appeals, and I am beginning to think that Lilly would prefer to forego the inevitable press onslaught that filing against the two would bring.
Why would the two get press attention? Because journalism is often predicated on the willingness of insiders in government, law, business and so on to listen to their conscience and, where appropriate, fink out their employers. Think Pentagon Papers, for example. Our democracy works pretty well as a result. So when big companies or governments go after reporters' sources in court and then try to get civil penalties levied against them, then the press has this habit of covering these matters because we take a very dim view of people monkeying with people who tell the truth. And have the documents to back it up.
For the longest time, psych researchers have been all-genetics, all-the-time to the point where most patients believe whatever disorder they've got is strictly as a result of mom and dad making babies and the generations of baby-making that came before that. Genetics. But that's not true nor is it wholly false.
Anyhow, here's a new study from the Archives of General Psychiatry going into anti-social behavior amongst youngsters, their genetic make-up and how mom and dad treat them. It's too complicated to explain so:
"Objective: To assess whether latent genetic factors and measured parent-child relationships interact in predicting adolescent antisocial behavior and depression....There was an interaction of genotype and both parental negativity and low warmth predicting overall antisocial behavior, as well as aggressive and nonaggressive forms of antisocial behavior, but not depression. Genetic influence was greater for adolescent antisocial behavior when parenting was more negative or less warm. Genotype-environment correlation was partialled out in the analysis and thus did not account for the results.Conclusion: This study demonstrates, on the basis of careful measurement and appropriate analytic methods, that a continuous measure of parenting in the normative range moderates the influence of genotype on antisocial behavior."
Fascinating.
For those of you interested in matters Paxil/Seroxat, GSK: License To (K)ill (a nice riff on the Beastie Boys album) has a ton of interesting items on the drug's approval in the UK. BTW, I wonder if one of the resident Paxil experts out there could fill me in on why we are seeing such an explosion of commentary on the drug in the UK but complete silence on these shores. Is the drug being used a lot over there still? Its use seems to have dropped off in the US. Just curious.
CL Psych takes my Paxil post of today and goes me one better. Read it.
depression introspection on a beauty queen cum pharma rep pressing for teen depression awareness campaigns in the Philly area. Nah, no self-interest there.
Orthomolecular psychiatry, diet and mental health. Interesting.
Someone ripping off Barbara Ehrenreich's prose on depression's weird roots in European culture.
Every fourth Austrian is mentally ill. I'll make sure to inform the Guvernator.
An Eli Lilly study showing that early non-response to an antipsychotic by schizophrenics means docs need to be more aggressive about switching meds. No doubt to Zyprexa.
Well, you had to kind of know this was coming: A Pennsylvania law firm announced yesterday that it had filed a complaint against Eli Lilly as part of a class-action suit against the company. A press release states:
"The Complaint charges Lilly and certain of its officers and directors with violations of the Securities Exchange Act of 1934 for disseminating false and misleading statements concerning Zyprexa, the Company's best-selling product. More specifically, the Complaint alleges that the Company failed to disclose and misrepresented the following material adverse facts which were known to defendants or recklessly disregarded by them: (a) that they were aware of the clear link between Zyprexa and diabetes; and yet failed to warn the public at large of the serious and material risks associated with Zyprexa use; (b) that they had engaged in an illicit scheme to offset a drop in sales that was certain to occur (and, in fact, did occur) when reports of Zyprexa's side effects surfaced, by creating a marketing plan for Zyprexa which included, as a primary component, the evaluation and pursuit of sales opportunities for the drug based on "off-label" uses; (c) that the growth rate in Zyprexa sales would not be sustainable once information about the health risks of Zyprexa and Lilly's illegal marketing plan were disclosed publicly; (d) that they disregarded data that undermined the "safety and effectiveness" of the drug; (e) that their "quality-assurance procedures relating to the quality and integrity of scientific information and production" as it pertained to Zyprexa were woefully inadequate; (f) that, by engaging in an illicit "off-label" marketing" program as to Zyprexa, they had not "enhance[d]" its policies and procedures designed to assure that its marketing and promotional practices and physician communications "compl[ied] with promotional laws and regulations;" (g) that they failed to warn the public of the serious health risks associated with Zyprexa use and that its illicit "off-label" marketing program was a direct violation of its own code of conduct as set forth in "The Red Book;" and (h) that their illicit scheme of concealing the side effects of Zyprexa and engaging in a massive illegal off-label marketing campaign potentially subjected Lilly to substantial regulatory fines, penalties and other legal action, thereby compromising the Company's overall financial condition and prospects."
I have not seen this so-called Red Book but methinks it has nothing to do with Chairman Mao.
Shareholders must be pissed at Lilly, especially now that the company faces lawsuits by seven states, a Congressional investigation and 1,000 or more remaining individual lawsuits (some of which go to trial this month)--and this is after having settled about $1.2 billion in class action lawsuits in the last 20 months related to Zyprexa.
Of course with such shareholder allegations, it makes you wonder if the SEC is far behind with its own investigation of Lilly as I pointed out back in February.
You just have to wonder when the other shoe--or shoes--might drop since, to date, the FDA and Congress have taken no substantive actions against the company over Zyprexa. And, for all the bloggers out there who like to bitch about the mainstream media (and pimp the whole Web 2.0 paradigm in the process), you'd be wise to remember that much of this wouldn't have happened without the work of the New York Times, which a judge was later dumb enough to call reprehensible, and a couple of people who leaked out the secret Zyprexa documents.
I'm sure the folks at Drug Wonks will find a way to spin this so they can claim that shareholders are trying to scare patients off their meds. Or do the claims of fellow free-marketers mean more to them than those of aggrieved patients?
Yet another paper from the NIMH-funded STEP-BD study came out yesterday in the Archives of General Psychiatry. In it, researchers examined patient outcomes for bipolar patients taking meds in the study who were also offered one year of intensive psychotherapy (family-focused therapy, interpersonal and social rhythm therapy and cognitive behavior therapy) or a brief period of collaborative care (3 sessions in 6 weeks).
Patients getting intensive therapy were recovered at the end of a year 64.4 percent of the time while patients getting collaborative care hit 51.5 percent. "Patients in intensive psychotherapy were 1.58 times more likely to be clinically well during any study month than those in collaborative care," states the study abstract.
Since STEP-BD has shown remission/recovery rates of about 30 percent to 35 percent for the meds-alone approach, I am guessing it might make some sense to crack open the old treatment algorithms and add something like CBT to the mix. Hell, even NAMI came out yesterday calling for more intensive psychosocial therapy based upon the study.
The new issues of the American Journal of Psychiatry came out yesterday and in it was a most interesting editorial. The editorial was authored by Boris Birmaher, a psychiatrist at Pitt, who was describing a new study of outcomes of young bipolar patients. I thought to myself, "Self, where have I heard that guy's name before?" So I went and did a little Google Scholar search and, sure enough, Birmaher is one of the co-authors of the 2001 paper based upon the controversial Glaxo Smith Kline Study 329 of Paxil/Seroxat in depressed teens that was the subject of the recent BBC "Panorama" program on Paxil. Study 329, in short, claimed that Paxil beat placebo in treatin depression in teens when, according to multiple sources, it did not. But that's context for this assertion Birmaher makes at the top of his editorial:
"Consistent with [Emil] Kraepelin’s early descriptions, it is now recognized that bipolar disorder may become manifest during childhood and adolescence. However, the diagnosis of children with this disorder may be difficult because pediatric bipolar disorder usually manifests with rapid mood changes, and therefore many children do not have the currently required DSM-IV duration of symptoms to fulfill diagnosis for bipolar I disorder or bipolar II disorder."
He goes on from there and describes the study elsewhere in the AJP and states:
"Despite these negative consequences and the fact that up to 60% of adults with bipolar disorder report the onset of their mood symptoms before age 20, there are doubts regarding the existence of this disorder in youths. Prospective follow-up studies of children with presumptive bipolar disorder may help validate this disorder."
In his mind, the whole early-onset bipolar disorder business is real, very, very real. But should anyone trust Birmaher? Should parents? Let's just say that some very smart people have taken on many of the issues around Study 329 and Paxil/Seroxat and, based upon the evidence, I'd have to say that it's fair to assert that none of us in the patient world should trust anyone who had a hand in the study (unless they want to suddenly recant the work) on absolutely anything they say about mental illness. At a minimum, we should be wildly skeptical of any claims they make. But, then, maybe I just have a problem with liars and I need to get over myself.
Healthy Skepticism, an Australian site, has done yeoman's work on Study 329 and other issues. You can find their resource page on the study here. Many interesting documents. In addition, CL Psych has written several smart posts about Study 329 banging on the study's main author and the journal that published the paper. And, of course, over in the UK there is an entire phalanx of bloggers delivering regular butt kickings to GSK over Paxil. Bob Fiddaman's Seroxat Sufferers site and Scientific Misconduct have been blowing apart the many ugly issues around Paxil for some time now. As well, AHRP has shown GSK much love and I have offered my own small thoughts here and here. I pass all of this along as resources for anyone who may be interested. (Check Fiddaman's blog roll to get a sense of just how much anger there is in the world about Paxil/Seroxat.)
Paxil is a bad med. As a result, I put little faith in the pronouncements of any doctor who pimped for the drug.
Thanks to those of you who bird-dogged my recent site tweaks. If anyone notices anything missing or wants to suggest other blogs, let me know.
Man on Lexapro gets worse, docs prescribe Paxil and Risperdal, three days later man jumps off bridge to his death, and his family sues. (Via Psych Data.)
Gianna at Bipolar Blast responds to my earlier posting on recovery.
Kansas Sunflower had a trying weekend adventure with sleep and Seroquel and it resulted in three posts. Here, here and here.
A patient struggles with how to tell her doc that she went off Lithium. Or whether she should even bother. Includes an interesting discussion of how docs and others in the mental health system disrespect patients deemed non-compliant.
Several interesting posts on the bipolar child controversy at The Trouble With Spikol, including this one.
The anti-smoking Nazis continue their campaign to keep people with "serious mental illness" from smoking. If you folks are so concerned about your patients' long-term health, then you were sounding the alarm about Zyprexa when?
Mind Hacks applies a bit of Miltonic verse to CBT. Good point.
Bad Science on some worries over Big Pharma being able to selectively inform doctors about the mechanics of medical conditions such as the mostly-unproven link between serotonin and depression. (Via Mind Hacks.)
For those of you in the DC area, Fred Goodwin and Kay Jamison, authors of the medical textbook Manic-Depressive Illness, will make a joint appearance at the Politcs and Prose bookstore on April 22 at 5 p.m. to discuss the second edition of the work. I cannot think of the last time a bookstore had doctors publicly discuss a medical text. That tells you a lot about just how prominent bipolar disorder, depression and good old manic-depression have become in our culture. I hope a DC reader goes to the event and takes notes.
The other day a reader, an older bipolar, posed some questions to me:
"How have you managed to find your way through it all? What do you do drug wise that you found to work well?"
I'm not sure that I have fully found my way through it all. I am on a good plateau at a good time in my life. My doctor, a fairly conservative psychiatrist as these things go, uses terms like "recovered" and "remission" to describe me. We've poked at the idea of me going off meds a couple of times. I guess I am in the zone in which a lot of other folks with a mental illness would like to be. But that makes me nervous after many years of struggle. It can all come unglued very quickly. What's more, the science base on what is "recovered" and whether people stay there is remarkably thin.
You'd think docs would want to study and write about people who do well, despite a major psych diagnosis, but they don't. I digress.
My point is I am uncomfortable with all the terminology out there (isn't "recovery" an AA thing?) and, hell, with everything I am about to say. It's one man's experience and one man's observations of hundreds patients and one man's reading of the clinical literature over the years. Seriously, I've talked publicly to NAMI and NMHA groups in Washington State and Montana about recovery. People sat there like I was going to turn them onto the Holy Grail. In reality, I had little to offer other than my own physical example--I was standing there, I had a semi-responsible job and I could speak in complete sentences. I don't even remember what I told them.
I've poked at some of these ideas before on this blog, so what follows is a rough attempt at trying to pull it all together. Really rough. One man's slouching toward recovery.
The biggest thing you've go to do is accept your diagnosis (and this comes from someone who has issues with some of the diagnoses and diagnosticians), or you are going to be wrestling with yourself for a long time. It's not worth doing. You know damn well that something is up with you, so what do you intend to do about it?
Two basic operating principles: No suicide. No giving up. Once you get those operating principles into your life, it gives you the ability get down to the most important matter of all, which is environment. You must have as much control of your total human environment as you can possibly manage. In the workplace. In school. At home. With friends. Out on the town. Anyone with bipolar disorder, depression and schizophrenia who's had it for more than 15 minutes and is somewhat reflective on their state knows that there are certain things and situations that don't work out well for them. Or which flat out screw them up. Like working too many hours. Or multi-tasking far too much on the computer. Or playing games with meds and dosages. Or whiffing a gram of cocaine. And so on.
But, yeah, creating an environment that works for you and creating a pattern of life that helps you is utterly essential. It is from our environments and human interactions, after all, that we draw most of the meaning in our lives, so it's a good idea to make whatever sacrifices you need to in order to square those away. Some of this is known as social rhythm therapy. I call it getting your shit together.
You've got to adopt a no-excuses mindset. This means you've got to stop blaming the illness alone when things get dicey. You've got to dispense with the learned helplessness that the mental health system in this and other countries impose on patients. It's fine to talk about depression as being bad and you need to try all the available treatments and so on, but there comes a point at which that whole approach takes far too much responsibility away from the patient for how they are progressing long-term (I am not talking short-term crisis situations here) and leaves the patient with little control of their own situation. This works out nicely for doctors and pharma companies, of course.
I sometimes think our mental health system in the US is little more than an immense learned helpless experiment ("There's a 30 percent chance you'll kill yourself!" "You won't hold down a job"). And we're the rats. Or the capuchins. But I digress.
You've got to get on as few meds as possible as soon as possible. I am sick and tired of running into bipolars who are on five meds at once--I ran into one the other night and it wasn't clear to me how the poor woman was standing up. The research isn't there to support long-term polypharmacy (to me, that's more than two meds), so why doctors are so willing to lean on it with patients for so long is beyond me (I've got no problem with it in short-term crisis situations). Feel free to point me to any patients who are on five meds and whose life has been sparkling success for years on end.
The truth of it is that every bipolar I've ever met who's done well long-term has been on one med, sometimes two.
But no matter how many meds you are on, you've got to accept that you will always have symptoms. From time to time, they will break through or you will feel them coming. It's a good idea to have a few methods of your own to address symptoms before things go full-on syndromal. I've covered this elsewhere before. If there's a med like Ativan or Seroquel or whatever that you can take for a few days to knock things down, then go for it. The other biggie is that you've got to eat regularly. And for god's sake, keep the processed food and refined sugar to a minimum.
Sleep is huge, too. It is also self-explanatory. As is getting a modicum of exercise. And so on.
My own feeling is that you've got to approach bipolar disorder as a personality disorder--or even as an environmental disorder--as opposed to a strictly biologically-based illness. You get to work on all the behavioral problems and cues and triggers then. I know that's a heretical thought, but so be it. I happen to find it empowering. I'll lay my money on individual humans and their wills any day.
"What do you do drug wise that you found to work well?" was the reader's second question.
What I am doing right now is Lamictal, 200 mgs. per day. It's not perfect, but it's a nice change from three and four meds at a time and the blasted atypicals. Back in the day, Lithium was pretty good for a few years, but then I made the mistake of letting the docs get me on Prozac and the like. And, as recent research shows, anti-depressants aren't especially effective for bipolars. The side-effects made me sick. Gee, it only took researchers 15 years or so to figure this one out!
Depakote was OK, too, for a time.
The bottom line with meds is that you've got to be in control of what you are taking or not taking. Doctors work for us, not the other way around. And, if you are unhappy with a med and want to go off, then you need to go off it under medical supervision--playing games with powerful medications is not smart.
That's all I can push out of my brain for now. Hopefully, it answered some questions. Or raised some other ones. Soon, I will come back to this subject by way of these "quality of life" studies that are now enjoying a certain vogue amongst researchers working with bipolar disorder.
A reader left this comment the other day and was OK with me putting it on the main page. I pass it along without comment, as it speaks for itself:
"My 27 year old son was put on Seroquel without any testing as AstraZeneca recommends to rule out any health challenges. He was making a major life change moving from Florida to San Diego Ca. the psychiatrist just handed him 40 tablets of Seroquel with a typed note to start with 25mg and increase as needed. He turned into a zombie a friend told us the first week out there and was starting to struggle with despair and suicidal thinking. He left Florida on the 21st of June and took his life the 21st of July. He just graduated 9 months before from the University of Gainesville, received a good paying job and saved enough money to buy a town house. He was not in debt or had any girl problems he just wanted to experience another place to live and stretch his mind but instead he lost it---a waste and sign of the times. The state investigated and stated that they could not find a probable cause--but I say it was a probable contributor since the time spent was so short and the decision was so irrational unless the chemistry was severly distrubed. All my research and contacting different people who were with him those last weeks seem to point to my son not being himself. The question was what criteria did the doctor use to diagnose for Seroquel and why give a patient drugs when they are no longer in their care. Never answered. But sharing the story will hopefully alert people to these quick fixes that can be equal to brain surgery--one slip up and a life is/can be ruined forever. Missing a part of our family of seven."
CBS' 60 Minutes had a piece on about just how much influence lobbyists for the pharmaceutical industry have in Congress. It's tons and, as with the Medicare reform a few years ago, has the taxpayers underwriting Big Pharma's bottom line. Here's a script of the piece.
As a journalist, I am a bit confused why the show spent time on this. They had no new news in it--the whole Medicare thing has been picked over for a couple of years--and there was no big bust, so why spend your resources on it. It's far from the knockout Big Pharma deserves. But what do I know about the mysteries of network television news programs?
Hey, CBS: you heard of this Zyprexa thing?
So I just did a bunch of updating of links and rearranging of links, mostly on the right hand side. Let me know if anything seems off. Or if I have overlooked some blogs. Thanks.