Bipolar overdiagnosis: are you swayed?

An excerpt from my book review on the new book by the Brafman brothers, Sway, in bookstores shortly: The one place the authors don’t really sway me is their attempt to explain why bipolar disorder is diagnosed so much more often than it was a decade ago. Unmentioned by the authors is the fact that many other mental disorder diagnoses have also experienced a significant increase in their use from a decade ago. They link the increase to two factors – the modern diagnostic system put into use in 1980 with the publication of the DSM-III, which “broadened” the bipolar diagnosis; and pharmaceutical advertising in the 1990s. Left out of this explanation are some of the reasons proffered by the actual researchers of the study (Moreno et. al, 2007). So what did the researchers who actually penned the bipolar “forty fold increase” say? Well, they were far more cautious about suggesting possible causes for the increase in diagnoses. But they did note that many of the symptoms of bipolar disorder overlap with other mental diagnoses, which could also be, in part, reason for the increase. For example, in a study conducted in 2001, nearly one-half of bipolar diagnoses in adolescent inpatients made by community clinicians were later re-classified as other mental disorders. Here is what one of the researchers of the study actually said: “It is likely that this impressive increase reflects a recent tendency to overdiagnose bipolar disorder in young people, a correction of historical under recognition, or a combination of these trends. Clearly, we need to learn more about what criteria physicians in the community are actually using to diagnose bipolar disorder in children and adolescents and how physicians are arriving at decisions concerning clinical management,” said Dr. Olfson. Sway’s authors’ suggestion that the increase in bipolar diagnoses is related to the modern diagnostic system seems to be reaching. If the DSM-III was the cause of the forty fold increase from 1994 to 2003 in bipolar diagnoses, why did it take more than 14 years to even reach the lower 1994 levels, long before the increase occurred? The authors also link the diagnostic system back to its founder, Emil Kraepelin, and imply that the DSM-III (and its current version, the DSM-IV) have no links to “hard science” (whatever that is). Of course that’s not true – the DSM-IV is nowadays very much based upon empirical data; Kraepelin’s original categories have largely been discarded in the modern version. Kraepelin’s concept of bipolar disorder in the early 20th century was that it included both the modern version of “major depression” and what we now call “bipolar disorder.” He did not, however, describe bipolar disorder as know it today and the authors’ implication that this diagnostic category remains largely unchanged for nearly a century is just ludicrous. As for pharmaceutical advertising, that’s likely a stronger link to the increase in diagnoses. Advertising largely works, otherwise companies wouldn’t bother. This too wasn’t a hypothesis of the researchers. But neither explanation really goes to any irrational behavior on anyone’s part. Yes, once a patient is diagnosed by a mental health professional, diagnosis bias kicks in – we tend to view the person only in the filter of their diagnosis (and most other professionals will adhere to the original diagnosis, perpetuating the bias). What the Brafmans do show is that diagnosis bias can lead to the patient themselves changing their behaviors to also fit the diagnosis. Once people are labeled, they tend to live up (or down) to those labels, or take on the characteristics of the diagnosis. The authors call this the “chameleon effect,” which is a person’s taking on positive or negative traits assigned to them by someone else. Except for this one section of one chapter, I otherwise found the book even more enjoyable than Ariely’s Predictably Irrational. Read the full (Source: World of Psychology)

Depression Treatment - Try these useful Home Remedies for Depression

People with depression are simply not able to carry on their lives normally. Without treatment, symptoms can last for weeks, months, or years. When these symptoms become very intense, they start interfering with ones ability to normally carry out even the daily chores. The person feels unable to do anything about it; other people need [...]

Blood Test May Identify Risk for Depression

Although major depression is a common condition affecting about 15 percent of the US population, the roots of the disorder have been difficult to ascertain.

What is known is that there are clinical parallels between depressive symptoms and the symptoms of certain inflammatory disorders.

In findings published electronically in Molecular Psychiatry, researchers from University of Miami found genetic differences — called polymorphisms — in inflammation-related genes that are associated with susceptibility to major depression.

The study population was made up of 284 depressed Mexican-Americans from Los Angeles who were already enrolled in a pharmacogenetic study of antidepressant treatment response. The control group was made up of 331 individuals from the same community.

“Our findings suggest that a simple blood test to look for these genes could help us identify people who are at risk for depression,” said Ma-Li Wong, M.D., professor and vice chair for translational research in the Department of Psychiatry and Behavioral Sciences at the Miller School of Medicine and lead author of the study.

“We would know to watch these people in stressful situations, such as a soldier in combat, and intervene earlier to get them the help they need.”

Interestingly, genetic variations in PSMB4 and TBX21 may also be relevant to two immune disorders, psoriasis and asthma. Both of these disorders are known to be co-morbid with major depressive disorder and are related to psychosocial stressors.

Source: Molecular Psychiatry

Bolder update: lilly started it

Some of my longstanding readers probably remember that I long ago wrote about a statistical issue in the Seroquel trials for bipolar depression (known by the corny acronym BOLDER). It was just a minor issue, you know, the kind that would make a drug look about 50% more effective than a placebo depending on which type of analysis you chose to use. No biggie. Lilly Started It: It just so happens that Philip Dawdy (who has apparently been christened as Dr. Dawdy) at Furious Seasons recently had a letter published in the Journal of Clinical Psychopharmacology on this issue of statistics. Dawdy noted that the authors' use of a statistical method known as mixed models repeated measures (MMRM) rather than the more conventional last observation carried forward (LOCF) resulted in a major inflation in effect size. As I mentioned earlier, the choice of methods to calculate the effect size (the magnitude of difference between drug and placebo) had a big impact. Dawdy aptly noted that the authors should have reported the effect sizes calculated by both methods so that readers could note how one method made Seroquel look better than did the other method. To quote Dawdy, "...the authors should also have reported the LOCF effect sizes so that the readers would have been aware of how the method impacted the findings." I was flattered to see that my blog was cited in Dawdy's letter. I heard through the grapevine that another author attempted to cite my blog in a letter to the editor, but that the journal struck the citation to my site in the final version of the published letter. If some of y'all researchers who read this blog wanna cite my site, go ahead. I'm not saying that Seroquel was a dud, but that it did get a boost from the analysis used in the study. When the authors are playing by a new rule when it comes to calculating the differences between drug and placebo, it would make sense to report the results using both the old rules and new rules. In his response, Michael Thase of the BOLDER team responded that "It is my understanding that mixed model repeated measurement (MMRM) analysis was chosen to compute effect sizes in the BOLDER studies because it would permit direct comparison with the results of the study of the only other treatment approved for bipolar depression, the combination of olanzapine and fluoxetine (OFC). Thus, in plain and simple terms, we were attempting to facilitate an apples to apples comparison between quetiapine monotherapy and OFC." So because Lilly did it, we did it. Um, OK. But is there some kind of law against reporting the results from both the newfangled MMRM analysis and the old-fashioned LOCF analysis? Just wondering. And if Lilly started saying it was okay to market Zyprexa off-label for various conditions, would that mean all antipsychotics could be marketed off-label for all sorts of issues? (Hypothetically speaking, of course.) Stats: Thase goes on to note that there is some research suggesting that MMRM does not overinflate effect sizes; rather, LOCF underestimates them. I know a bit about stats, but I'm not a statistician. Basically, the differences between the methods boil down to how data is handled for persons who dropped out of a study. The best solution is to try to track down study dropouts and assess how they are functioning, rather than having a statistical model guess at their sense of mental well-being, but this requires extra effort and time, and is sometimes not possible. Basically, the LOCF model makes some assumptions that are quirky at best, while MMRM seems to handle missing data better in many situations. All that being said, in many trials where a drug beats placebo, MMRM appears to generate effect sizes that are higher than LOCF, which then leads us to a question "Geez, have we been underestimating the effects of drugs by 50%?" -- um, that seems a little hard to swallow. I'm not quite ready to buy into that. (Source: Clinical Psychology and Psychiatry: A Closer Look)

Optimistic Recovery Videos

Positive messages and success stories about individuals with mental illness who have found hope and recovery are helpful for other who may feel less optimistic. They can help ease worry about future outcomes, and provide role models.

Here are a couple of videos that provide very sunny stories to inspire you: the first is a production from SAMHSA (who also brought us the super-cheerful web site What a Difference a Friend Makes) along with a handful of other government partners. The University of Washington hosts the video, available to download or watch streaming online. It begins with a message from the Governor about how valuable employees with mental illness are, and concludes with people beaming and waving sparklers, in between telling the stories of three people with mental illness who’ve gone back to work. Check it out: I Want to Be.

The other video is also from the Pacific Northwest. Stories of Strength spotlights several people in recovery in Vancouver, BC. Being provided an apartment, that allows pets, in prime downtown real estate near the beach, has been very helpful to a woman recovering from addiction.

I feel an urge to go dance through a meadow now.

No, but seriously, excuse my cynicism - housing and employment supports can be absolutely crucial to recovery and wellness. These videos are quite inspiring, so if you’re feeling glum about your prospects there is hope, and here are some people who provide it.

The Army’s Response to Rise in Suicides, PTSD

Today I participated on a U.S. Army-sponsored conference call to discuss their reaction to data showing that 115 active soldiers took their own lives last year (nearly double the rate from 2005) and approximately 17 U.S. veterans commit suicide each and every day (significantly more than reported to Congress last year). Statistics also show a nearly 50 percent jump in new posttraumatic stress (PTSD) cases last year when 13,951 service members were diagnosed with combat stress, compared to 9,549 in 2006.

The Army says it is working hard to improve access to mental health care among the troops, to reduce the stigma often attached to seeking counseling, and to train and educate soldiers to recognize signs of stress in themselves and their comrades. But senior officers also acknowledge there is much more work to be done to help soldiers deal with personal problems compounded by the stress of combat.

The challenge is familiar. The military is under extreme stress for the prolonged deployment in Iraq, which nobody planned for and which the military was clearly not prepared for. Stigma related to seeking treatment for any mental health concern — even combat-related PTSD — remains the biggest obstacle to helping reduce the number of suicides. The Army has started the process of decreasing the stigma and negative reinforcements by changing the security clearance questionnaire where respondents no longer have to indicate a mental health issue if related to their military duties.

But it’s a drop in the bucket in terms of the real life stigma experienced in individual units and under C.O.s. Seeking mental health treatment while in active operations is akin to signing your own declaration of, “I have no interest in career advancement in the Army.” It remains a sign of weakness and discrimination. Until Army leaders are held responsible for the repercussions carried out under their commands, little significant change will occur.

On today’s call were three U.S. Army representatives: Col. Elspeth Ritchie: psychiatric consultant to the Army Surgeon General; Lt. Col. Thomas E. Languirand, Chief, Command Policies and Programs Division; and Chap. (Col.) Charles D. Reese, Office of the Chief of Chaplains. Col. Elspeth Ritchie did most of the responding. Today’s call also covered questions asked by other military bloggers:

1. Can there be an improvement in the Army’s crisis resources? Something better than just going to ER and told to go home if not actively suicidal? The answer was basically, no, not at the moment.

2. How about more inpatient programs made available to military personnel? The representatives basically said that nothing is available right now, but they are looking at something in-between once a month and inpatient — an intensive outpatient program. This sounded like something akin to a day treatment program for veterans and would be a welcomed addition to the treatment options open to vets.

3. What about all the alternative treatment programs mentioned in the news at the end of March? Virtual reality, yoga, etc. They are just in research phase right now and not widely available until proven their worth.

4. A question was asked about some recent legislation introduced in Congress that would expand mental health care to military vets. Col. Ritchie responded, “Anything that can improve access to care, we should take advantage of. We need to expand our network of tri-tier providers.”

5. How will Army remove PTSD stigma, given its long history within the military? “Part of this is education, we did this major training where we taught every soldier about TBI (traumatic brain injury) and related issues. We’re looking at policies that discriminate against mental health. The security question, for instance, is one change we’ve undertaken,” replied Col. Ritchie. She also emphasized the importance of strong leadership ensuring such stigma is not tolerated within their units.

It was a very short phone call (the coordinator kept emphasizing how little time we all had; it lasted about 25 minutes in length), and I felt like we could’ve easily had another 30 minutes of questions to ask and explore. But I do appreciate the U.S. Army’s willingness to engage with bloggers and allow them to pose questions regarding some of these chilling statistics.

Col. Ritchie also noted some interesting statistics about the availability of mental health professionals overseas which I’m not sure are widely known. There are approximately 200 behavioral health providers (e.g., military therapists) in Iraq and 30 in Afghanistan. That’s about one therapist per 600 soldiers versus one therapist per 375 Americans in the U.S. civilian population. Given the significantly greater stressors and risks for mental health concerns a soldier in active military duty is likely to experience, these numbers seem backwards. There should be twice as many therapists available to soldiers are there are to civilians, but there isn’t today.

One thing Col. Ritchie emphasized is the Army’s recognition of the suicide and PTSD rates as problems and their current challenges in resources. They know these are issues and are working to correct them. We hope they do.

And we hope the military leadership recognizes that this isn’t just an urgent issue in the services, but something that could just as easily snowball into a crisis of significant concern. Without real efforts made now to help stop this trend, we could see next year’s suicide rate double again in the active service. It’s a datapoint we’d rather not have to document.

Cancer Survivors Have Many Unmet Needs

Many long-term survivors of cancer are not receiving the necessary aid they require to help them live with the consequences of their disease, its treatment, or both.

Currently, there are approximately 25 million people around the world (10 million in the USA) living with cancer, and over 60 percent of adults newly diagnosed with cancer can expect to live at least five years or more.

Marie Fallon, Professor of Palliative Medicine at the University of Edinburgh, says many of these patients are living in limbo with unmet needs that should be addressed urgently.

“Traditionally, palliative care has been aimed at one end of the spectrum where it is used to help patients near the end of their lives,” she says. “However, there is an enormous population of long-term survivors of cancer, many of whom are living with a range of symptoms.

Some of them will not know whether they are cured and whether the symptoms they are experiencing are treatment-related or whether they are related to recurrence of the disease that has not yet been diagnosed.

“These patients exist in a limbo. They fall between two stools: they have finished being treated by oncologists, but are not receiving the care and support from palliative care teams that patients at the end of life receive. Yet the impact of cancer and cancer treatment on the long-term health of survivors is substantial and many of them remain very symptomatic, with poor quality of life. Clearly a proportion will unfortunately be diagnosed with recurrent cancer at some point.”

The problems cancer survivors face can include pain, sexual difficulties, troublesome lymphoedema (chronic swelling caused by the failure of lymph glands to drain properly, often triggered by surgery and radiotherapy), and psychosocial problems including depression and anxiety.

To highlight these “large gaps in patient care”, Prof Fallon and John Smyth, Professor of Medical Oncology (also at the University of Edinburgh), have co-edited a special issue of the European Journal of Cancer on Palliative Care.

The EJC is the official journal of ECCO – the European CanCer Organisation – and Prof Smyth is its editor-in-chief as well as being a past president of ECCO.

“We aim to use this special issue to bridge the gap between oncology and palliative care, and to encourage integration between the two disciplines,” says Prof Fallon.

“Collaborations and systems need to be developed to care for patients at all stages of their disease and not just those who have a formal diagnosis of recurrent or advanced cancer.”

In their EJC joint paper, Profs Fallon and Smyth write: “We need to develop a particular supportive care model for sick patients and traditional palliative care expertise should feed into this model. Life and illness are a continuum and our patients do not always fit into well-defined boxes. As specialists, our challenge is to accommodate this continuum rather than restrict it.”

Prof Smyth says: “Europe has led the way in the development of palliative care, which is now an increasing focus of attention in the USA.” The EJC special issue on Palliative Care will be available at ASCO and Prof Smyth will be highlighting it in discussions at the conference.

Professor Alexander M.M. Eggermont, current ECCO president, commented: “This is an important special issue of the EJC, for everyone to read and discuss its content. To be cured from cancer, but living with symptoms that are related to often complex multidisciplinary treatments involving surgery, radiation therapy and chemotherapy is already difficult enough.

“To reintegrate into society, resuming work full or part-time adds to the complexities and socio-psychological pressure that an ever-increasing number of ‘former-patients’ have to deal with. All this must be looked into and will need special initiatives to deal with these special and unmet needs of this population. We better start tackling these issues now as they will only increase in number and magnitude.”

Source: ECCO-the European CanCer Organization

Latest Medications for Bipolar Affective Disorder

Within the last five years there have been several substantial breakthroughs in research toward finding the true biological cause of bipolar affective disorder. This research has lead to the development of several new bipolar affective disorder medications. A few of the more popular latest medications for bipolar affective disorder are described below. Abilify, or Aripiprazole, [...]

Two psychiatrists on newsweek’s bipolar child

Recently, Newsweek had a cover story on a young kid diagnosed with alleged bipolar disorder. I've already ripped the piece apart. I felt it failed to deal with the lack of evidence for the disorder in children and didn't even bother to quote critics within psychiatry of the controversial diagnosis. It lacked the level of balance I would've expected from the magazine. My views, of course, are one thing. Those of psychiatrists are another thing entirely. Last week, Peter Breggin, a critic of much of current psychiatry who happens to be a psychiatrist, was a bit over the top when he wrote that psychiatry had declared "war" on the boy, Max. I understand his frustrations, but war is a bit much. Then he makes an extremely valuable point about what this boy, who's been on 38 different meds, and his parents will be up against: "From now on, Max, his family and his doctors will almost certainly have to face an increasingly impossible dilemma common to children who are prescribed multiple psychiatric drugs for a period of years. When trying to withdraw these children from multiple psychiatric medications, they almost certainly go through severe withdrawal problems with extreme emotional instability and the risk of worsening violence and suicidality. In fact, we are told that an attempt to take Max off his medications resulted in his displaying hallucinations and delusions, which Newsweek attributes to his worsening condition and his need for drugs. The odds are overwhelming, instead, that he went through a severe withdrawal reaction. So it can be very difficult to withdraw children like Max from multiple psychiaric drugs, but if they are kept on drugs indefinitely, their brain, mind and overall condition is almost certain to deteriorate." Regardless of what you make of the bp kids paradigm, Breggin is precisely right about withdrawal problems and that some of this kid's symptoms could well be generated by a reaction to medication withdrawal, or to the meds themselves. Maybe he magazine will do a follow up article someday. I was intrigued by Peter Kramer's views on the article on his blog at Psychology Today. Kramer is of course the author of Listening to Prozac, which just passed its 15th Anniversary in print, a stunning accomplishment, regardless of what you think of the book (my views are mixed). Kramer, who globally seems to like the article, raises an interesting point: "A note regarding diagnosis: Yes, the Newsweek text and headlines are pitched to an interest in bipolar disorder, but who knows what this kid has? Mary writes that Max’s secondary symptoms include hyperactivity, anxiety, obsessionality, attention deficits, dyslexia, and pronounced elements of oppositional-defiant disorder. A current movement in psychiatry favors “dimensional” diagnosis, cataloging scattered problems rather than grasping for syndromes. This trend can be taken too far, but especially in the case of children, whose disorders are often protean, the approach can signal an appropriate agnosticism." His subtle point is that he thinks the magazine shouldn't have pushed the bipolar angle on this kid so hard because "who knows what this kid has." I wish the magazine had been a bit more sensible as well, given the many controversies in the field over this matter. It's clear that something is up with little boys like this, but what it is no one really seems to know with anything approaching certainty. For those of you who want to read the thoughts of a defender of the disorder in kids, you can do no worse than John McManamy's post over at Health Central. He's been an extremely harsh critic of anyone who questions bipolar disorder in children, and his tone is often one of religious conviction. I've noticed that tone to be consistent in late-diagnosis bipolars, as McManamy is. You've got to wonder what's driving that. Maybe he can take on Breggin and Kramer now. (Source: Furious Seasons)

Therapies Reduce Post-Stroke Depression

New research discovers administration of medication or participation in a problem-solving therapy group lowers the risk of depression in the year following a stroke.

The study is published in the May 28 issue of JAMA.

The annual incidence of stroke exceeds 700,000 in the U.S. with depression developing in more than half of these patients, according to background information in the article.

“Post-stroke depression has been shown in numerous studies to be associated with both impaired recovery in activities of daily living and increased mortality. Prevention of depression thus represents a potentially important goal,” the researchers write.

Robert. G. Robinson, M.D., of the University of Iowa, Iowa City, and colleagues assessed the efficacy of the anti-depressant drug escitalopram or problem-solving therapy compared with placebo pills for the prevention of depression among 176 stroke patients.

Within three months following the stroke, the patients were randomized for 12 months into one of three groups: escitalopram (n = 59); problem-solving therapy group (n = 59); or placebo (n = 58). The problem-solving therapy group consisted of six treatment sessions and six reinforcement sessions and included patients selecting a problem and going through steps to arrive at a course of action.

The researchers found that participants who received placebo were 4.5 times more likely to develop depression than patients who received escitalopram (22.4 percent vs. 8.5 percent), and 2.2 times more likely to develop depression than patients who received problem-solving therapy (11.9 percent).

“Based only on the frequency of depression onset during the one year of treatment, 7.2 acute stroke patients would need to be treated with escitalopram to prevent one case of depression and 9.1 acute stroke patients would need to be treated with problem-solving therapy to prevent one case of depression,” the authors write.

An alternative, more conservative method of analyzing the data found that escitalopram was superior to placebo (23.1 percent vs. 34.5 percent), while problem-solving therapy was not significantly better than placebo (30.5 percent vs. 34.5 percent).

There was no significant difference between groups in the frequency of adverse events.

“The clinical implications of our findings are that patients who are given escitalopram or problem-solving therapy following acute stroke may be spared depression and perhaps its adverse consequences,” the authors conclude.

Source: JAMA and Archives Journals

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