April 14, 2008

First Anniversary Of The Death Of Antidepressants

Belated, anyway.

A year ago-- 4/4/07-- the NEJM published a study that said\ antidepressants did not provide additional benefit to mood stabilizers.  But my tin foil hat allowed me to see that the authors were abandoning antiepileptics and antidepressants; the future was in bipolar, and in antipsychotics.    We are now for monotherapy, and it is branded. 

I wrote about it then, received slightly more than the usual hate mail ("are you a psychiatrist or a scientologist?") had a drink and went to bed.  What else am I going to do?

Time passed.  Seroquel got an indication for bipolar depression; Abilify for adjunctive use in depression.  SSRIs are history, Cymbalta a last holdout due to an extra indication.  And I haven't seen a Depakote rep since, well, since a year ago.

If you're new to the game, it will be hard for you to believe that in 2001 Depakote was everywhere.  If you dared to start a "bipolar" on anything other than an antiepileptic, you were actually reprimanded by other doctors.  "What the hell is this nut doing over there?"    Back then if you said you were going to use Seroquel for... anything, they caned you. 

Now it's the top selling psych drug.

I briefly toyed with asking Calabrese, Bowden, Sachs, et al-- the Mafia of Psychopharm-- for a formal apology; or at least an admission that they were wrong, but now I see that that's impossible: not because they are hiding it, but because they actually believe they never said it.  They think they were always pro-antipsychotic monotherapy; that they never intended Depakote to be first line; that they never implied there was considerable evidence that Depakote should be a maintenance agent, when in fact there was none.  They don't realize how much a pawn in the academic-Pharma  game they are.

I fought a solitary battle against this thinking back then, and I'll say it was with some not inconsequential professional repercussions. 

Whatever; my point isn't to say I was right, but to show that they were wrong--and now pretend they never said it.  So that the next thing they say can be met with at least a little skepticism.

It's like Iraq-- first it was WMD, everywhere, all the time; now they don't talk about WMD, but worse, they pretend that they never really meant WMD.    

Difference is no one trusts Cheney anymore; but somehow, we still ask the Mafia of Psychopharm to lead us. 

I'd trust Cheney over any of them, any day.


It looks like the industry ... (Below threshold)

April 14, 2008 7:39 PM | Posted by Demodenise: | Reply

It looks like the industry itself is bipolar.

What will happen next, when the patents are up on the atypicals? Maybe just benzos for the manic and amphetamines for the depressed?

Wait. . . why am I suddenly having this intense feeling of deja-vu? Why, I'd better go talk to my doc . . . . I hear there are some great meds for dealing with that kind of thing.

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Thank-you for your truth-te... (Below threshold)

April 15, 2008 7:56 AM | Posted by Diane Abus: | Reply

Thank-you for your truth-telling.This is a scandal I'm enjoying alot.Seroquel rant was my fate for two years before I showed that doc the door.Best....

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Speaking of bipolar, is it ... (Below threshold)

April 15, 2008 3:48 PM | Posted by JC: | Reply

Speaking of bipolar, is it just me, or is it suddenly becoming epidemic? In fact, I have patients coming to me demanding that they be labeled "Ultra-rapid-cycling" bipolar instead of possessing borderline personality traits. I see more patients wanting to relabel themselves as "chemically-imbalanced" instead of learning to manage their moods. This leaves me frustrated for my patients who I believe actually do experience manic and hypomanic episodes. However, perhaps we should start with a more fundamental issue - our diagnostic system.

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JC wrote:"In fact,... (Below threshold)

April 15, 2008 6:06 PM | Posted by AK: | Reply

JC wrote:

"In fact, I have patients coming to me demanding that they be labeled "Ultra-rapid-cycling" bipolar instead of possessing borderline personality traits. I see more patients wanting to relabel themselves as "chemically-imbalanced" instead of learning to manage their moods."

Dear JC: My therapist told me that, yes there has been a trend these days for persons with borderline to be given a DX of bipolar. The incentive is to protect people from the stigmatization of a BPD diagnosis.

The problem is that this is misplaced kindness. The two conditions are different and require different forms of treatment.

My take as a lay person (correct me if this is incorrect) is thatBPD is entrenched by disruptions in parent child bonding between age 0 to 18 months and is triggered by abandonment & relationship issues,

By contrast, bipolar is far more a genetic/medical psychiatric condition and can occur even if one receives 'good enough mothering'. Bipolar episodes are triggered by stress (which can include but not be limited to relationship issues. A friend with bipolar who is on medication told me he needed to adjust his meds after he had a bad scare following a motorcycle accident--the stress started to throw him into a manic episode and he had to phone his prescribing psychiatrist.)

Bipolar shifts can also be triggered by disruptons in sleep wake cycle. A social worker with both professional and personal experience concering bipolar told me that it is important for many persons with bipolar to not only get 8 hours of sleep but to get up at dawn, and not attempt to start the day before sunrise. I heard of yet another person who reported that their first bipolar manic episode was triggered by their first airplane trip outside of the US--airline travel through multiple time zones disrupted the persons sleep wake cycle. Manic episodes can be seasonal and can also be triggered by antidepressants.

All of this is very different from borderline personality disorder.

A sad result of labelling borderlines with bipolar diagnoses is that borderlines will be less likely to get the exact treatment they actually need, and persons with bipolar will risk incurring the kind of cruel stigmatization that boderlines have had to contend with. All of this does no one any favors.

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For lack of a better term, ... (Below threshold)

April 15, 2008 6:09 PM | Posted, in reply to JC's comment, by Demodenise: | Reply

For lack of a better term, it's "in" in the industry to be bipolar at the moment. Kind of like how a couple years ago suddenly *everyone* had GAD. . . funny how it coincided with an antidepressant getting approved for treatment of anxiety (was it Zoloft or Effexxor XR? I can't recall. . .)

The symptoms that your patients are presenting with haven't changed, just the terms that we use to define the groups of symptoms has changed. . .suddenly, someone with comorbid depression and anxiety is experiencing a bipolar "mixed episode." And bipolar mixed is preferential to a dual diagnosis of depression and anxiety, because we have shiny pretty meds for bipolar!

Same thing with the ultra-rapid-cycling and BPD. It's just switching a term with a bad connotation (BPD = difficult clients with no emotional regulation) with one that is PC at the moment (and has shiny pretty meds associated with it!)

Of course, then it becomes a matter of ethics. Do you let the person with the borderline characteristics call him/herself bipolar, and whip out the pad for a couple months' worth of Seroquel? Or do you stick to your guns and say, "sorry, you're not bipolar" and risk losing the patient to another Dr. that will write a script for what the patient *thinks* they need? Or does it not matter at all what the terminology is, if taking the Seroquel is increasing the patient's LOF and not doing any major harm?

Oh, wait. This isn't my blog. . . .(sorry, Alone!) *steps off soap box, goes back to reading.*

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(Another bit of input for a... (Below threshold)

April 15, 2008 6:11 PM | Posted by AK: | Reply

(Another bit of input for a layperson)

Regarding Seroquel...stop me if I am wrong, but some time back, I read a friend's package insert. I think it mentioned that Seroquel could increase risk of developing Type 2 diabetes.

If this is indeed the case, shouldnt we pause and ponder the implications?

Rates of Type 2 are already unacceptably high. Before folks run around prescribing Seroquel, make damn sure that 1) the person doesnt have risk factors for insulin resistance/Type 2 and two, that he or she actually has a condition for which Seroquel is appropriate.

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A couple comments about wha... (Below threshold)

May 31, 2008 5:52 PM | Posted by Jeffrey T Junig MD PhD: | Reply

A couple comments about what I just read here... It is certainly true that many patients who we used to call 'Borderline' are now labeled 'Bipolar'. One of my practices includes the Wisconsin Dept of Corrections, where I treat women at Taycheedah, a max facility, and men at Oshkosh Correctional Institution. Almost every female patient has been diagnosed as 'bipolar' at some point in life before coming to prison, whereas in most cases I consider them to be borderline. There are many reasons for this; I think that many psychiatrists (incorrectly) see Borderline PD as 'untreatable', which makes them uncomfortable with the diagnosis. Another very common reason is that when you ask BPD patients about bipolar symptoms, they almost uniformly endorse them-- whether you ask criteria for mania, for hypomania, or for depression. Of course, BPD patient also frequently endorse psychotic symptoms. One of the writers above described the two conditions as very different; they certainly are very different as far as etiology goes, but there is a great deal of similarity between the symptoms. Yes, lack of sleep can trigger mania, but distinctions such as these do little to help separate the diagnoses 'in the trenches', as any BPD patient will tell you that yes, she becomes more 'manic', becomes more irritable, and has more 'racing thoughts' when she doesn't sleep, as just one example. The other difference that I wish was more helpful is that BPD patients have 'mood swings' many times per day, whereas even rapid-cycling bipolar consists of 4 or more mood changes per YEAR. But again, in the trenches the patients will change their descriptions of their moods to fit whatever they need to get that bipolar diagnosis... As we know, BPD patients see the withdrawal of a med, or a comment that recognizes improvement, as abandonment-- and so they just love to have bipolar, and will go to great lengths to keep the diagnosis.

I will disagree a bit with the comments about treatments; more and more, the same meds are used for both conditions, with similar results. The atypicals will stabilize mood in bipolar and reduce impulsivity and activation in BPD; the effects look quite similar in some cases. Valproic acid is similar-- mood stabilization in bipolar, and reduction in the intensity of anger in BPD. Even DBT, the standard therapy for BPD, will likely improve the functioning of most axis one patients, including those with bipolar.

Regarding the comments about mothering, remember that while most psychiatrists carry an image of a BPD patient at the lower end of the socio-economic ladder, that is not always the case. A person does not have to be 'abused' to develop BPD; a person may just have a mother who is always passing the kid off on the 17-y-o nanny who doesn't care for the baby, or the mother may be more tuned into tennis and cocktails than into changing diapers. Sorry by the way for contributing to the guilt of all women who aren't perfect in every way...

For disclosure, I should say that I am one of those psychiatrists who consider bipolar to be over-diagnosed to a HUGE extent.

Regarding Seroquel and type II diabetes, the issue has been thoroughly examined by some very solid research, called the Catie trial. (CATIE: Clinical Antipsychotic Trials of Intervention Effectiveness). Zyprexa is the worst in regard to causing 'metabolic syndrome', Geodon and Abilify are the safest in that regard, and Risperdal and Seroquel lie in the middle.

Finally-- I hope I can add this information without getting blocked-- I see psychiatry as the last hope for the preserving the good parts of the traditional doctor--patient relationship-- as long as the psychiatrist is able to control things, and to keep appointments of a sufficient length to truly get to know the patients. I have established a forum for independent psychiatrists, meaning any psychiatrist who is employed by self or by other psychiatrists, or who at least is shooting for that type of situation in the future. It is all free, and all new, and I would love to have any psychiatrist passing by join me and tell a bit about him/herself. You can register as yourself, or use an alias if you prefer: http://independentpsychiatrists.com . Don't forget to make it plural. Please stop by.

Jeffrey T Junig MD PhD

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The message I get from this... (Below threshold)

June 24, 2008 3:47 AM | Posted, in reply to JC's comment, by acute_mania: | Reply

The message I get from this blog, as well as my own experience as a patient is that "actual" mania and to an even greater extent since it's less obvious, hypomania are just as subjective and stigmatizing and arbitrary as "possesing borderline traits". And of course, every DSM revision which adds features to a diagnosis means more people can fit or be shoehorned into meeting the diagnostic criteria. But this huge increase in bipolar diagnosis will mean less stigma for the severely mentally ill (with the bipolar label anyway), because bipolar will no longer connote being seriously fucked in the head. I was at a bipolar support group, and the people there were trying to shoehorn themselves into fitting into this bipolar label they had gotten (And Dr. Junig, I don't think you have to be borderline to do this. Being able to write your quirks off to something independent of your character is incredibly seductive). "I know that when I start doing heavy cleaning, it means I'm getting manic" Huh? Heavy cleaning=mania? I remember telling the group that I used to be able to get by with five hours of sleep and now with my meds I was groggy with ten. "Yeah, but that's because you were manic" "Really?" "You think anyone taking seroquel can get by with 5 hours of sleep?" This one woman there seemed to enjoy collecting diagnoses like notches on her belt, she told us she had just been diagnosed borderline. She was taking eleven psych meds. What kind of idiot psychiatrist would do that to a patient? I'm still young and have a lot to figure out about life, but at least now I don't expect psychiatry to give me answers as to what the hell is wrong with me, only more questions and doubts. That said my current med is working pretty well, but then again the same med would work for me just the same if I had a different diagnosis or a different psychiatrist.

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Your description of what ha... (Below threshold)

June 24, 2008 4:14 AM | Posted, in reply to Jeffrey T Junig MD PhD's comment, by acute_mania: | Reply

Your description of what happens to borderline patients on meds is pretty much what I've been told by my psychiatrist. But notice the way you worded it. "stabilize mood in bipolar and reduce impulsivity and activation in BPD" Does reduction of impulsivity and activation not count as "mood stabilization"? The term "Mood Stabilizer" connotes a specific treatment for "bipolar disorder", so your wording serves to validate the view that bipolar is the "biological" disorder whose treatment is a mood stabilizer and "borderline" the personality disorder whose symptoms can be masked with the medications. This distinction is totally arbitrary. This is the point this guy drives home in his blog.

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The way I worded things-- r... (Below threshold)

July 19, 2008 1:46 AM | Posted, in reply to acute_mania's comment, by Jeffrey Junig MD PhD: | Reply

The way I worded things-- referring to mood stabilization, impulsivity, and activation, is a list of three totally different things. To answer your question-- no, reduction of impulsivity and activation do NOT count as mood stabilization. Psychiatry is an imprecise science, if it is science at all. But it does have certain definitions that are used precisely-- and not in the vague way that you imply. Mood refers to the general sense of happiness of a person that is prevailing over a long period of time (as opposed to affect, which is short duration). Mood has nothing to do with impulsivity nor with activation-- they all describe internal states and observable traits, but they come from different parts of the brain and are different subjective and objective experiences. So no, in this case the distinction is not at all arbitrary, although I can see how it would seem that way when the definitions are not used correctly.

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Hello, I've recently been d... (Below threshold)

December 7, 2008 8:40 PM | Posted by Elanor: | Reply

Hello, I've recently been diagnosed with Bipolar II, having a real hard time with this. I am in denial and do not want to take the medications. I am a 36 YO female who have three children. I'm really stuck here. I know the benefits from the medications. My question is in a person who is not bipolar and had been taking medications (SSRIs) can they develope mania and not really be bipolar. And if so what sapports this.

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Haha, also dxed bpII. Every... (Below threshold)

May 2, 2009 4:53 AM | Posted by Anon: | Reply

Haha, also dxed bpII. Everything alone wrote is everything my psychiatrist is treating me for/with

1) dx with bipolar II,
2) given seroquel PRN/abilify,
3) absolutely no mood stabilizer/depakote,
4) will not entertain possibility my descriptions of symptoms are normal or personality based

I'm taking the drugs though. I recognize abilify to be helping with my depression, but it doesn't help the craziness part other than softening the symptoms (or sometimes making them more severe, ironically). Tonight I tried seroquel prn for agitation and it definitely made me relaxed and then put me to sleep but I woke up shortly with hunger.

I was told I might have TLE. I need to see a neurologist. Yet she still won't give me an anticonvulsant to cover bases. Only monotherapy with aaps given the fact I report being insane.

Sigh. I really must be either bored and/or desperate to go along with this.

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A negligent doctor , gave m... (Below threshold)

March 18, 2011 3:13 PM | Posted by GRIEVING MOM: | Reply

A negligent doctor , gave my son a cocktail of meds including Seroquel that SUDDENLY KILLED HIM. cause of Death Myocarditis. he was 28y/o strong, humble and leaves a 2 y/o precious daughter!

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