I won't give a detailed answer to this question here (it seems to be no), but there is an article making the reddit rounds now that I need to kill before it becomes another meme (like that other badly reported story about psychiatry.)

The article is from BMJ 2002, called Influences of the Media On Suicide, and it puts its conclusion right at the top:

Reporting and portrayal of suicidal behaviour in the media may have potentially negative influences and facilitate suicidal acts by people exposed to such stimuli. Recent systematic reviews by others and ourselves (unpublished) have found overwhelming evidence for such effects.1 (emphasis mine)

And it offers about 8 references in support.  And so now every nut with a microphone can proclaim it loudly: it's the media's fault.

We may want to take a pause and examine these 8 references: none of them offer anything close to "overwhelming evidence."  For example:

Reference 1-- the one directly cited for the above statements-- is indicative of the type of "overwhelming evidence" that exists. The study finds that media reporting of suicide is extensive and detailed, but not that there is a clear link to future suicides.  

In the summary, the authors use phrases like, "dearth of literature," "evidence is less reliable," "few studies permitting/demonstrating [the link]," "does not demonstrate consistency," "many studies fail to demonstrate" over 11 times in the 3 pages describing the studies. 

Despite this, they are sure the link exists-- but they don't actually show the link, they infer a link.    The authors repeat phrases, "it is fair to conclude that the evidence suggests an association [exists]" "tends to suggest," "probably reasonable to regard the association is causal"  13 times in two pages.  Under these criteria, it's reasonable to assume the Matrix is real.

Reference 3 (not even linked correctly) is a letter to the editor, describing two cases, where the method of suicide was affected by internet, but not the decision to commit suicide.  And the methods were rather weak: one guy took two pills of castor oil, and the other woman tried to drink water.  No, I'm not kidding.

Reference 5 is frequently cited in support of media's impact.  It supposedly says that a TV show with a Tylenol OD caused more Tylenol ODs: 20% of these suicidal viewers said it influenced their decision to attempt suicide in the first week post broadcast.  Maybe-- that 20% is really 6 people.  And most had attempted Tylenol OD in the past.  Oh, and the authors note that while 17% of the suicidal viewers' choice of Tylenol was influenced by the show, some of them chose not to use it because of the show.

Reference 12 is probably the most cited reference in this field.  In 1978 Vienna built a subway, which soon became a popular method of suicide.  So the government established guidelines for reporting-- specifically, that the method not be mentioned-- and subways suicides decreased by 80%.  Fantastic.  Overall suicide rates didn't change, though.  Too bad. 

So much for the "overwhelming evidence" for a soon to be media soundbite. 

The article doesn't make a good case for media influencing the decision to kill yourself, though I'll admit that it may influence the method.  And that's where it gets tricky.

It's important to make a distinction between copycat suicides and copycat homicides: more poeple die in the latter, and, let's postulate, they didn't want to die. That has to be part of the calculus in media reporting. Copying suicide by water (instead of pills) is different than copying a 30 person massacre (instead of killing, say, one person.)

But you have to weigh this against the societal costs.  The solution offered in these articles is to restrict media reporting.  I think we can agree that the media are neither liberal nor conservative, but  sensationalists, their bias is titillation.  But to allow anyone, especially government, to affect the content of reporting-- literally, the information we are allowed to have-- seems exactly the wrong solution to a problem which may not actually exist.  (e.g. I know it seems prurient, but I actually want to know all the details of David Kelly's suicide.)

Not to mention that if you say the media are partly responsible, then you're saying that you're less responsible.

(More on copycat suicides here, and on university suicides/copycats here and here.)

A reader commented that I was minimizing porn's negative effect on women, that ubiquitous internet porn has damaged womens' psyches irreparably.  That it makes women have to conform to some impossible standard.

Nay.

Porn is not the problem.  I'm not saying it's a tremendous boon to society, but you can't blame porn for failing relationships, the pressure on women to attain impossible standards of appearance and performance; and male disinterest in normal sexual relationships.

Certainly porn puts pressure on women, but the effect is not directly from porn, or even from men.  Here's an example that the reader offered: porn forces the women to shave.  Not exactly-- they want to shave.  Why they want to is a cultural discussion, but it isn't because men are explicitly commanding them to do so.

Certainly, porn has affected men.  Ok, women want to shave; why do men suddenly want to, also?  And, I'd expect that a frequent porn user (whatever that exactly is) might have some difficulty with arousal in normal (or repeat) circumstances.

But there's a greater problem that can't be blamed on porn.   Every comic since Marx (Groucho, not the other nut) has joked about how men want sex and women don't.  But in the past three or four years, I've heard comics make the opposite jokes: women want it, men could just as easily pass it up.  Men are disinterested in sex with their established partners.  As comic Mark Maron put it, "[I prefer masturbation because sex] takes up too much energy and it involves other people."  Men always are ready for new women,  but what happens to sex with your partner over time?  Sure, ordinarily it may decline a little, but this is different: this is male disinterest, "lack of energy," lack of motivation to keep a connection with one's partner alive.  The penis may still go up-- but everything else is gone.

Let's face it, porn may make women feel inadequate, but how the hell adequate can a woman feel if  her boyfriend/husband would rather watch TV than have sex? "But I'm tired."  How tired could you possibly be?

So there are two parts to the problem.  The easy, and smaller, part is media/porn objectification of women, and its effects on women and men.  But the second, more crucial part is male "impotence" (metaphorical) and apathy.   Let me be clear about this: porn might magnify this effect; but it doesn't cause it. 

I know no girl in the world is going to believe this, but it's true: if you ask the average guy over 30 if they'd rather be with a girl they have been with many times before or masturbate, they'll pick masturbate.  You know why?  Because their soul bailed out when they were 15-- because they are  narcissists.  What in life is worth aspiring to?   You don't feel a part of anything bigger, everything seems distant, unreal.  Everyone is waiting for something to happen, for their life to "start"-- they're 40 and they're still waiting.  (As Mike Birbiglia joked, "I'm not going to get married until I'm absolutely certain nothing else good can happen in my life.")  Concepts like loyalty don't even get a token nod, because today they seem outright preposterous. 

And men have a distorted view of what it means to be loved.  They want to be loved not for who they are, but who they think they are.  "I'm an actor."  "I'm a major force in WoW."  "I'm a fiscal conservative but a social liberal."  What he wants is his girlfriend to say, "I love him because he is such an intellectual, he knows so much about politics."  What he doesn't want is her to say, "I love him because he's good to me."

"Sure it'd be better to be with a girl, but when are you actually ever with a girl?  They don't want you, they want what you represent-- a good job, security, to be taken care of, a big penis."  It doesn't occur to them that the woman who doesn't want these things in her man might be the one to avoid?

I suspect-- I haven't been able to do the survey-- that even sex is a form of masturbation for these guys. That they see you, but they don't see you.  The arm, the breast, the hip, all these become fetishized and transport him to another world.

Our birth rate is 2.1; France 1.7; Spain 1.3; Russia 1.3.  In two generations, there will be 1/2 as many Spaniards, excluding immigration.  We can't even get it up long enough to procreate.   That's not porn's fault.  It doesn't help, sure, having the internet's tubes tied isn't going to fix that problem.  Men are becoming less interested in establishing meaningful relationships with other people as an ultimate goal than in inventing identities for themselves.

You're going to say that I made this up.  I am not making this up.  I wish I was, because then I could say,"stop making things up," and everything would be ok.  But it really happened, and I can't stop things from really happening.  So I drink.

This is the conversation I had with another psychiatrist.  He is wearing a Ermenegildo Zegna suit.  It fits him well.

I say, "... so if I have him [hypothetical bipolar depressed patient] on Depakote and Seroquel, once he's stable I try to reduce the dose, or even stop one of the medications."

He shakes his head. "I would never stop the mood stabilizer."

"Why-- wait, which one's the mood stabilizer?"

"The Depakote."

"But how do you know it wasn't the Seroquel?  That's the problem with starting two drugs immediately, you don't know which one worked."

"Well, you need them both.  Especially if you're adding an antidepressant."

"What antidepressant?"

"Seroquel." 

"Seroquel's an antidepressant?"

"In this case it is, you're using it for bipolar depression."

I blink my eyes, to make sure I still can.

"Then what's the Depakote?" 

"The Depakote is the mood stabilizer."

"But how do you know the mood stabilizer isn't the Seroquel?"

"The Seroquel is the antipsychotic."

A voice tells me to stab him.

"Why can't you just use the Seroquel-- the antipsychotic- slash- antidepressant-- alone as a first try?  What benefit does the Depakote give you over the Seroquel?"

He says it slowly, enunciates, because he deduces that I don't speak English.  "Because the Depakote is the mood stabilizer..." 

He looks at me. I look at him. He is wearing a yellow Bolgheri tie.  In my mind it is on fire.

"...Besides, if you use Seroquel off label like that, you'll get sued."  Blaming lawyers, the last refuge of the incompetent.  "And for what?  Why take the risk?"

It's at this point I realize he's not wearing socks.  "If you're going to use that logic, Depakote isn't indicated for mood stabilization, either." 

He looks at me incredulously, then suddenly he realizes something.  "Oh, okay, right, I see what you're saying now... but at least Depakote has FDA approval for Bipolar Disorder."  QED.  He's very happy now.   I can't find the waiter.  Why is my drink empty?

There's an uncomfortable pause.  He wants to show me he's a skeptic, too, that he's carefully pondered these issues.

"I have a theory, have you ever used meclizine (a drug for vertigo) as a mood stabilizer?" 

"No, I had never heard of that."

"I haven't tried it either, but it might make sense: meclizine stabilizes your balance, so perhaps it could stabilize your moods?"

I want to call the State Board of Medicine but realize I'm in a different state and I don't have the number in my phone.  "I doubt the insurance companies would ever cover it."

He slowly, purposefully, nods his head.  "Fucking meddling managed care."

 

I tell people all the time, don't get sick, don't ever get sick, but no one listens to me. 

 

Quick speculation. As 13 year old kids like this usually create an identity from multiple sources- so far we're pretty sure the main movie was Oldboy-- I wonder if he didn't also identify with the Question (the comic).  He signed his name as a question mark, he wore the same baseball cap, gloves with short sleeve shirt.  And, in case you weren't once a lost male adolescent, the Question is Vic Sage, ex-philosophy major turned TV reporter who is also a vigilante.  And the 30+ issues are all about his struggle with identity.

None of this is relevant to why he did it, of course.  It's fun to speculate, but of no predictive value.  These are costumes, roles.  They just help him "get into character," which in this case is a man alone fighting injustice, greed, and abuse, using whatever tools he has.  Of course, he was fighting college kids, and his tools were semi-automatics, but who am I to dispel a good illusion?

Finally, let me reiterate that the presence or absence of mental illness is irrelevant, at least as far as prediction goes. So let's say he was a violent schizophrenic.  Would you jail him before he commits a crime, just in case? Bush does that with Guantanamo, you know.  Do you send him to a psych hospital, like they do/did in the USSR?  That process will be magnificently abused by your government, I assure you.

More posts on Cho here, here, here, and here.

A few weeks ago I had used a Lost storyline to explain  my own view that we pick our own identities, rather than have them given to us through either genetics or the environment.  I made Desmond the Abraham in Kierkegaard's Fear And Trembling.

The crux of the episode and the analogy is that Desmond thinks he can see the future, and see that Charlie will die.    But Desmond then makes a vital moral step: he decides that it is also his responsibility to keep this character alive. (Quoting myself:)

The real question is why Desmond actually believes such a choice exists.  How does he think he knows the future?   Anyone else in his shoes would have come to a very different, more logical, conclusion: this is insane.  What, he can predict the future?  Worse: what, he's the only reason Charlie is alive?  He's so-- necessary?  Isn't that narcissism?

If Desmond knew he could predict the future-- if it was a fact that he could predict the future-- then saving Charlie would have little moral heroism.  Any fool a step up from absolute evil would have tried to prevent a horrible outcome if he knew for certain what was going to happen.

What made Desmond worthy of admiration was, exactly, that he did not know for sure he could predict the future. He took it on faith that he could, and then proceeded to live his entire life based on this single, faith based, assumption.

 

That was Feb. 15.  Strangely, I just saw last week's episode, in which Desmond turns out to have once been a a monk, and he has a discussion about Abraham and Isaac with another monk; the wine they make is named Moriah; and later Desmond explicitly references the test of faith-- straight out of Fear And Trembling. 

I suppose this could be a coincidence. 

Another possibility is the writers read and and love this blog and have gone and reshot future episodes based on my ideas.  HA!

Another possibility is I write for Lost.  HA HA! 

But the final possibility is the most likely, and it has less to do with Lost and more to do with the direction of our fiction.

Pre 9-11, fiction, and especially sci-fi, had a distinctly post-modern flavor.  The main character wasn't really a person, but reality-- that it was wrong, or hidden.  This culminated in the Matrix.  The important concept wasn't altering reality for some purpose; it was that reality itself was a fabrication, the Demiurge hiding real reality behind a fake one.

The story goes that Darren Aranofsky (director of Pi) and Jared Leto walked out of the Matrix and asked, "What kind of science fiction movie can people make now?"  The point was that the  postmodern slant, cyber-realities, etc, were done as well as they could be. So, too, CGI.  From now on anything else would be coattail riding. (Think how Pulp Fiction degenerated into Go and 2 Days In The Valley.)  The genre was finished.

So what's next?  Well, for Aranofsky the answer was the mind (see The Fountain), but I'd suggest an even broader answer: ideas.  The next genre of sci-fi, or fiction- has to be about the conflict of  ideas, identities.  

If I was going to write a novel-- and who says I'm not?-- I'd take advantage of our societal narcissism, our search for identity-- and, more importantly, for excuses why we have certain identities; our fear of death manifesting as age-postponement; and the decline of truly meaningful relationships to write a sci-fi novel about what really keeps us linked to each other.

The operative question would be: if you could be anyone, had unlimited power, what would be the ethical system you use to make choices?  Who lives, who dies, who suffers, who doesn't?  How do you decide?

The first element would be Faith.  So, with a parting wave to postmodernism, the protagonist can see the future or alter reality, except that he's not sure he can do this.  Worse, every time he alters reality by avoiding a future he has supposedly seen, he creates a new future he didn't predict-- but this is, of course, no different than normal life.  In other words, by avoiding the future he predicted, he negates the proof that he saw the future.  So he has to have Faith that he has this power, in the absence of any evidence. The protagonist of my book won't have any objective evidence that he is right or doing the right thing, he simply will have to believe, to decide, that he's right.  It has to be identical to, say, psychosis.

In Lost, Desmond still has objective evidence that he predicted the future, even though it gets altered; he sees an arrow; they did talk about Superman; the parachutist looked the way he foresaw it.  So this isn't exactly a leap of faith.  Similarly, if Abraham really knows God exists, then sacrificing Isaac isn't wrong or even strange-- God wants, God gets.   

Unlike Desmond, who has to decide only if he should save Charlie, my character would have to both decide he can see the future, and also that it is his responsibility to act on it.  This brings us to:

The second element, Duty. In making these decisions and accepting these beliefs-- altering reality along the way-- he'll have to establish a hierarchy of good and bad.  What is he supposed to do?  Does he have any duty towards anything?  For the plot, this will require some symbol, metaphor.  A good one might be a piece of jewelry-- some object which changes depending on the chosen duty. It's a ring, it's a sword, it's a bandage, etc-- it's the same "object" that he carries, but it changes.

The third element is Rage. When you believe something that no one else believes-- especially if you believe you are somehow better, or even different, than others; and if others directly oppose you in this belief, the inevitable consequence is rage.  How to depict this?

The fourth element is Love. The negating force for Rage.  This character will need to identify what he loves, and how-- platonic, romantic, etc; a plot-trick might involve altering reality and therefore altering the character of his love (for example, a woman he loves may later become his sister, etc.)

To make the reader share the magnitude of the protagonist's Faith dilemma-- in order to ensure that the reader does not "suspend disbelief" and automatically buy into the protagonist's powers (the way we have with Desmond,) you'd have to write the book from the perspective of a second character, who describes the story of the protagonist.  You should never actually get to interact directly with the protagonist, you should never actually hear him speak, only this second character.   This way, you're never sure what to make of the protagonist or his adventures. 

Preliminary thoughts, anyway.  Looking forward to the next Lost and JJ Abrams stealing my ideas.  ;-) 

 

A thoughtful reader concerned about backlash against the mentally ill asked me to write a piece basically saying that not all mentally ill people were homicidal maniacs. 

It's a fair request, but in this case it's counterproductive.  Here's what I mean: you want to say that "not all mentally ill people are violent."  You want counterexamples to Cho's example.  But that's a defensive posture, unnecessary because... Cho wasn't mentally ill.  He was a sad, bad man who killed people because his life wasn't validated.  There was no psychosis, there was no cognitive impairment, there was no psychiatric impairment in insight in judgment.  There was a lack of sex, but that's not yet in the DSM.

Not to reduce his life down to a soundbite, but he was a guy who thought he deserved better by virtue of his intelligence and suffering; found himself in a sea of mediocrity but couldn't understand why he couldn't therefore excel; and, worst of all, found that all the things he thought he deserved eluded him-- especially hot chicks, who not only dismissed him and found him creepy, but, worse, chose to be with the very men he thought were obviously inferior to him.  It's Columbine all over again.  It's almost even the same day.

Forget the Prozac, forget the involuntary commitment (where he was found by the court to be "a danger to himself and others"-- that's standard boilerplate, it is clinically meaningless).  Those are  red herrings.  You may as well blame wearing black t-shirts.  He's not mentally ill; he's an adolescent.

The difference, the single difference, between us and him is that when we were sulking in high school, we listened to Pink Floyd or U2.  He watched Oldboy.  We had a battered copy of a Playboy down at the creek under a rock, that was so creased we had to infer the boobs.  He had the internet.  Maybe we bought a pocket knife, or-- wow-- a butterfly knife.  He bought two Glocks.

In other words, the difference is this: he decided to shoot 30 people, and you didn't.  That's it.  I know it's not a satisfying answer, I know we want explanations, but there aren't any.  Forget genes, forget DSM.  He chose to do something bad,  he knew it was bad, but he did it anyway.

Don't worry about the mentally ill.  Worry about the nut politicians and media outlets who will look to the easy and convenient excuse of mental illness, rather than have to do the hard work of figuring out why our society is melting.

 

Older posts on Cho here, here, and here.

A reader (who wants me to write an article on autism and paternal age-- I swear I'm getting to it) sent me a reference to a 2007 article finding an increased rate of schizophrenia in those born to parents who were dry cleaners (all Jewish, negating a racial association).  The authors speculate it's tetrachloroethylene exposure.

There were 4 cases of schizophrenia, out of 144 dry cleaning families.  What's interesting is that in 3 of the schizophrenia cases, the father was the dry cleaner. 

How does it happen? There are two possibilities: one is that tetrachloroethylene is neurotoxic in developing fetuses, so the dad must have somehow brought it home with him to the pregnant mom.  Or, it affects male sperm/ germ cells.

As for Cho, I don't know if his parents were dry cleaners in Korea, or if they started when they all came to the U.S.  But something worth investigating.

BTW: not that this would excuse him even if it were true. 

To Leslie, the reader: if you want credit, put in a comment and I'll put your contact info up here.) 

I still haven't had time to really look at this situation, but I have to address this nonsense about his psychiatric history: it's irrelevant.

He didn't do this because he was on Prozac, or he was Bipolar.  Look at it the other way: are we going to say that people with bipolar are more likely to go homicidal?  If so, should we do a Kansas v. Hendricks for bipolars? (in which the Supreme Court said it was ok to lock up pedophiles indefinitely, even in the absence of a crime, since "pedophilia" makes you a priori dangerous.) 

If you want to really understand why he did it that way, you have to find out what article of media he was imitating.  Take the photos, the manifesto, and google it until you find the movie the handguns came from; the book (or comic book) the manifesto came from.  He didn't come up with this stuff on his own, he is imitating something.  For Klebold and Harris it was the Matrix and Doom.  What movie is he imitating?  Find it.

Because it isn't about mental illness, or genetics. It's about identity, it's always about identity, and sometimes the identity you choose doesn't work out that well.  So, emergently, you grab an identity which has appeared to work-- you imitate a movie, a game, a comic.

I'm not saying movies made him do it; I'm saying he was looking for an excuse to do it, and he went through the usual catalog: movies, comics, games. Come hell or high water, he was going to kill someone.  But in terms of prediction, the operative question is, if this guy goes homicidal, how will he do it?  He didn't strap explosives to his chest, not because it wasn't available, but because it didn't match the identity he wanted to have-- that he got from a TV show or movie.

Ismael Ax, handgun to the head, hammer cocked like a bat to the right, knife to the neck-- all those stills from his video clips you see on CNN aren't random, they're a specific imitation of something else.  Find the thing he was imitating, and you have found him.

Because he didn't exist, that's the problem.  He picked an identity, and no one liked it, it backfired- no chicks-- so he moved to plan B: pick an identity that absolves him of the guilt of shooting 30 people. 

Stop looking in the DSM.  Start looking in IMDb.

 

I know nothing more about the case than anyone else with a FIOS connection, but for what it's worth, "Ismail Ax" seems like a gaming avatar.  I know a lot of people are trying to link it to Islam, who knows, maybe, but if anyone out there is tight with the gamers-- especially True Combat and Battlefield 2-- or if you have a teenage son-- I'd ask around.

So the APA has come out against the sexualization of women in the media.  Praise Jesus.  And not a moment too soon.

Oh my God.  If society could just expand it's historical horizon past winter, we'd realize that women have been sexualized for centuries.  It's only in modern times that women are allowed to be in control of it.

No. I'm not worried about girls, What we should be worried about are the boys.  What happens to a  boy who is told by the media that women are sexualized, they are objects, they are sluts?  And then he goes out into the world and discovers they aren't?  That they won't sleep with him?  That, try as he might, they won't do all the things he was promised in ads, movies, porn?  But they might be willing to do it with someone else, even women?

Depression?  Or maybe misogyny?  And maybe he starts hating women so much he, oh, I don't know, shoots 30 people at a college?

Women have been tweezing and preening and primping since day uno.  Near as I can tell, porn hasn't drastically altered this.  Interestingly, it has made young men more self-conscious, not just about penis size, but also body hair, fat, fingernails, etc.  The cultural problem is neurotic, immasculated men whose only outlet is masturbation and violence. 

Are we going to be honest or political? I don't know any women who if given a choice would prefer "not sexy" over "sexy."  If I have a daughter, I would want her to be in control of her sexuality, not under the control of it (in other words, the opposite of me.)  I want her to be smart and sexy.  I just want her to be her.

No.  No, the problem isn't my daughter becomes a slut; it's that she gets beaten by some whacko who wants her to be.  Or doesn't want her to be. Or does, but only when...

The real problem for the women of our society isn't a lack of self-esteem.  It's a lack of weapons. 

And no, I'm not kidding. 

In my post on the NEJM article about antidepressants in bipolar depression, some people couldn't see how I made the leap to a political movement away from SSRIs and seizure drugs, and towards atypicals.

First, I'm not against atypicals.  I have long advocated for fluctuating doses of antipsychotic instead of Depakote.  I do think they can treat depressive states.  I don't disagree with the study or the data. 

What I find perplexing is the timing.  I was trying to show how academic psychiatry has now decided to move towards atypicals.  Why now?

Here's an example.  Eduard Vieta just released his hit single, Current Approaches to the Treatment of Bipolar Disorder With Atypical Antipsychotics, in Primary Psychiatry.  In it, there is only one short paragraph on Depakote, describing its one maintenance study, in which (it states correctly) Depakote didn't beat placebo.  That's it.  81 words.

Find me one other article written before 2007 that is so curt and dismissive of Depakote.

It goes on to explore the data on atypicals-- and there's quite a bit.  It rightfully concludes, "atypical antipsychotics have shown promising results in bipolar disorder maintenance therapy."

But here's the point: with two exceptions, all studies on atypicals referenced here came from 2004 and earlier.  The two exceptions were from 2005.

So it's not new data, it's old data.  Did they suddenly read the back issues?  Holy crap, atypicals might work?  That's why that NEJM piece is so important.  It marks the point where academia has decided to embrace atypicals and move away from Depakote.  If this move was really data driven, they would have done it in 2004.  Hell, they would have done it in 2001 when the Depakote maintenance study didn't beat placebo.

There's no conspiracy here, there's no exploitation of the weak for personal profit.  I'm not saying these are bad people, not at all. They are not conscious of it.  That's what makes this politics, not science.

You have an academic career, you want to do clinical research, who's going to pay?  NIH money is hard to get.  So you turn to Pharma.  You "get" to do a clinical trial of  Depakote for the treatment of bipolar.  When you're done, maybe they hire you to do another one.

You, personally, don't even get the money-- the department does, and they use it to pay your already set salary. But you get a career, an identity.   But you start to believe the prejudices of your chosen stomping grounds, and ignore the shortcomings.  You become a nationalist.  You start to believe that Depakote is first line, despite data; or that all seizure drugs will work; or that this thing you called bipolar is actually what you're treating.  That there are actually two poles. 

Then the money dries up.  But Abilify says, could you do a clinical trial of Abilify for bipolar?  And you say, sure, why not? maybe Abilify could be an add-on?  And then it's monotherapy.  And then Seroquel funds a study. 

The last part is when you don't simply move on from Depakote-- you distance yourself from it.  "You know, its data was never that great, it was really just an antimanic, and anyway, it had horrible side effects."  It's the next step of political hypocrisy: I was never really a citizen of that nation, I have really always been a citizen of the world.

I recently read Martin Gardner's review in the New Criterion of Lee Smolin's The Trouble With Physics, and Peter Woit's Not Even Wrong: The Failure of String Theory.

I am almost finished Smolin's book, but I wanted to make a comment about Gardner's piece.  Writing in the New Criterion, he should have appreciated a wider view of the books, that they speak to more than physics.  They're just as much about psychiatry.

Write this day down: 4/4/07, it is the first day of the new psychiatry.  Everything changes, starting today.

Today, in the New England Journal Of Medicine, is an article ostensibly about the lack of additional benefit from adding an antidepressant to a mood stabilizer.  This is both surprising and not surprising: surprising, because, well, you'd think two drugs would be better than one.  Not surprising because, well, if the first drug worked, why would a second even be necessary?  (See #8). And if the first didn't work, how do you know the improvement didn't come entirely from the second drug? 

If this is all the article said, it would not be worthy of mention, let alone the herald of a new dynasty.

The study also found that the studied antidepressants did not induce mania.  That this should have been prima facie obvious even to a 9 year old without the benefit of eyes (what's an antidepressant?  They're not all chemically similar, so why should they all be blamed for the same side effects?) isn't the point here. 

The true importance of the study is contained in three statements.  If you blinked, you would have missed them.

The first is this:

Mood stabilizers were initially limited to lithium, valproate, the combination of lithium and valproate, or carbamazepine. In 2004, the protocol was amended to define mood stabilizers operationally as any FDA-approved antimanic agent.

The second is this, from the abstract:

Our study was designed to determine whether adjunctive antidepressant therapy reduces symptoms of bipolar depression...

And the third is this:

In summary, for the treatment of bipolar depression, we found that mood-stabilizing monotherapy provides as much benefit as treatment with mood stabilizers combined with a standard antidepressant.

Psychiatry is not about science, it is about language, politics.  What's happened here is that "mood stabilizer" now includes atypical antipsychotics; and-- compare what the study was designed to show and what they spun it to show-- we've gone from "polypharmacy is not better" to "monotherapy with mood stabilizers [read: antipsychotics] is just as good as two drugs at once." 

There's a subtlety there, and that subtlety is magnificent.

Note the authors: Sachs, Bowden, Calabrese, Thase, etc-- the same people who pushed psychiatry into flowchart polypharmacy; where Depakote was always first line for all phases of bipolar disorder, and any exacerbations that developed were treated with the addition of a second medication.

What the article is saying is that academic psychiatrists are no longer behind antidepressants and antiepileptics.  SSRI and SNRI use will decline from here, as will Depakote.  They're behind antispychotics.  And antipsychotic use is positioned to explode. 

It goes without saying: only the antipsychotics are still branded.

But without academics pushing SSRIs, their use will wane--and, importantly, so will their support of the diagnosis "Major Depression."  This is going to sound controversial, inane, but it will happen.

Look for upcoming articles finding that "Depression" is overdiagnosed, that it is really just-- life.  Look for articles that now find SSRIs aren't that effective after all, that the old "10% better than placebo" is a statistical trick with little clinical utility.  That they are way overused in kids.

You might say, wait, isn't the decline of polypharmacy  a good thing; that SSRIs are overused in kids; that they aren't that great; and that depression is overdiagnosed?  All of this is true, but this isn't psychiatry finally coming to its senses; this is psychiatry entering the manic phase.  Sure, it's less SSRIs for kids; but it's more antipsychotics.

Because simultaneously there will be articles pushing the idea that recurrent unipolar depression is really bipolar depression; that there are common genetic or heritability patterns; that the epidemiology and course is similar, etc. The move will be to squeeze out MDD into "life" and bipolar.  This done, antipsychotics become first line agents.  Oh, and look for antipsychotics to get FDA approvals for kids.

I wish I could make this clearer, but I'm still recovering from my recent bout with death.  There's no science here, only a tinkering with language and loyalties, with staggering results.  Don't blame Pharma quite yet-- this is a NIMH study.

I am not against antipsychotics, and I have long tried to tell anyone who would listen that the data clearly show they are superior to antiepileptics.  But this isn't psychiatry suddenly waking from a coma, aha! it turns out the existing data do show antipsychotics are mood stabilizers!    Instead of using them to replace antiepileptics, they will use them to replace everything: SSRIs, benzos, antiepileptics, stimulants, etc. 

And polypharmacy will only be reincarnated-- in the form of multiple simultaneous antipsychotics (Abiliquel, anyone?), with preposterous pharmacologic justifications ("this one acts on serotonin, so it's the antidepressant, and this one on dopamine, so it's the antimanic.")   If anyone says that to you, stab them.

You don't get many changes like this, maybe once every ten years-- the last was the beginning of the Depakote era, and before that was the advent of SSRIs, each with it's own erroneous semantics ("kindling model;" "serotonin model of depression.")

I wish all the patients in the world good luck, you'll need it.  Not because of the antipsychotics themselves, which will work or not, oblivious to doctor and diagnosis; but because of the doctors, who take little interest in examining the evidence behind their practice, and even less interest in reevaluating its core principles; and who lack the courage to even treat what they see, instead resorting to artificial, and wrong, paradigms and algorithms.  There's not even pseudoscience here.  Psychiatry is being lead by the siren call of semiotics, and it is saying, follow me, I am made of words...

Here's a little case report, about me, a cautionary tale about working too hard.

I had to go to Chicago for a case. It took three days.  It took a lot out of me.  There was the jet lag, and the work, and skipping meals, and sleep deprivation.   I barely sleep at home, but all I could get in the hotel was 2 hours/night.   I usually drink about 3 cups of coffee (16 oz each-- so I guess that's 6 actual cups)  a day, but with this level of stress and tiredeness I was drinking 4-5.  And, dare I admit it, I took a Provigil.

I could feel myself getting sick on the last day.  Just get through it, I thought.  Sick later.  Work today.  

I got home, exhausted.  The next morning I felt sick, wiped out, achy.  There you go, I said.  I have the flu.  I struggled through work, taking naps when I could.    

As the day progressed, I got worse.  Weakness, tiredness, horrible nausea, headache.  I gagged at the thought of food, but I forced myself to at least drink Gatorade.  Gatorade is the artificially sweetened sweat of male bicyclists.  Every word of that description disgusts me.  I drank the purple one.

Day 2 came, and I was worse, not better.  Not even the same-- much worse.  The headache was ruthless.   The nausea had become motion sickness-- turning my head was a lunar launch.  The arthralgias, bizarrely, had disappeared-- except in my neck, which had become very painful and stiff.  I couldn't turn my head well.  I could barely walk, I could barely think.

I went to work.

The weakness and lethargy had also changed-- into narcolepsy.  It wasn't weakness-- I was drugged.  I fell asleep for only a second at a time, but it overtook me every moment I wasn't active.  Driving.  Watching TV.  Standing at a urinal.  On an elevator.  During phone calls.  I could not stay awake.  Simply closing my eyes would drop me into Stage IV sleep.  I could still be talking, but if my eyes were closed I was asleep.  And what I said was nonsensical.

I was almost helpless.   I took Tylenol.  Motrin.  Tylenol + Motrin.  Nothing.  And I could not stay awake.  The head and neck hurt so much that the only solace was sleep, which I couldn't stop anyway.

What kind of flu was this?  And something worried me: why didn't I have a fever?

By day 3 I had what can only be described as the worst headache of my life.  The nausea was constant. 

Worst. Headache. Of. My. Life.

I rarely get sick, I rarely take pain relievers.  I do 3 sets of 50 push ups a day.  I'm pretty healthy, and I've never been incapacitated.  I only say this as background for my next sentence: I was so sick I could not see. 

Light hurt me, hurt my head.  I could not look at the monitor, or TV.  I wanted to be in a quiet, dark room-- asleep.  With morphine.  And the medical student in me solved the mystery: headache, stiff neck, photophobia, no fever.    I had finally done what I had been threatening to do for so long: I had popped an aneurysm.   I thought: so this is how it ends.

Nausea.  Headache.  Neck stiffness.  Exhaustion.

Exhaustion. 

Oh my God, could I be in caffeine withdrawal?

As soon as I thought it, I knew that was it.  I couldn't believe it.   I'd never felt it before because I'd never not had coffee before.  And that first day back, being a little off, I skipped it-- which made me worse, and then the withdrawal hit.

I made some coffee.  It smelled like battery acid.   I put ice in it and drank it, one cup all at once.  I gagged, twice. 

Within ten minutes, I was 10% better. In 30 minutes, I was 50% better.  In an hour I was 95% cured.  From unable to move, to almost complete cure.

Jesus.  

The cure was so total, the reversal so profound, that I actually couldn't remember how sick I was.  I thought I must have been exaggerating.

So my body reminded me.

Four hours later, I started to feel that motion sickness again.  By the fifth hour, I was on the floor again, same stiff neck and headache. And the nausea was worse: the thought of drinking the battery acid again was too much for me. 

But I did it.  And again, an hour later, I was completely cured. 

How "real" is caffeine withdrawal?  Clearly, my own experience takes it out of the theoretical realm.  But what about:

the average coffee junkie when he goes to the hospital? 

the psych patients who smoke 1 or 2 packs a day, 4 or 5 coffees a day, and get admitted on the unit where it's only decaf and a smoke break a shift? 

The case reports of neonates born to heavy caffeine drinking mothers, who went into serious withdrawal.  Three neonates had caffeine in their urine!  Symptoms include irritability, rigidity, hypertonia and hyperreflexia.

And then there are the kids.

What about all those kids who drink a lot of soda-- say, two cans/d (100mg total)--and maybe sometimes they don't get their dose?  One study of such 10year olds found that missing one dose of 100mg made them less alert, had more headache, and performed more poorly on cognitive tasks.  But how many parents (or doctors) would have thought about this? Another study also found kids in withdrawal got little headache, but get more myalgias than do adults. Who is savvy enough to attirbute these subtleties to caffeine?

Has anyone else wondered if the prevalence of ADHD doesn't parallel caffeine use and sleep deprivation, especially in kids (kids don't take naps anymore)?  And remarked that the main treatments are-- stimulants?

 

Referencing myself: What is the best and healthiest coffee to drink?