McMAN’S DEPRESSION AND BIPOLAR WEEKLY
July 3, 2002 Vol 4 No 23
Note: This
excellent newsletter is available weekly from:
http://mcmanweb.com/newsletter1.htm
VINTAGE BREW There has been only one study of postpartum psychosis in the last
30 years at the National Institute of Mental Health, said E Fuller Torrey MD,
who needs no introduction, in a keynote address to the NAMI annual conference
held last week in Cincinnati. Over the same period, he let his audience know,
there have been 22 studies of how pigeons think.
This is the kind of hyperbole that got Dr Torrey on 60 Minutes in May, with
Morley Safer nodding in apparent agreement. Call him a master of the outrageous
- Dr Torrey is also a master speaker and educator, passionate about what he
believes in, and watching him perform before a crowd, especially in the
equivalent of his home court, makes one realize why he is perhaps the best-known
psychiatrist in the US.
The good news, he told those in attendance, is that we know how to deliver
high-quality, cost-effective services to individuals with severe psychiatric
disorders. The bad news is we're not doing it. Jails are replacing hospitals
for the mentally ill, with the LA County Jail, the Cook County Jail, and Rikers
Island in New York City serving as the nation's three largest de facto mental
facilities. The LA County jail spends $10 million per year on psychiatric
medications, alone. The quality of life for individuals with psychiatric
disorders in jail is abysmal, with beatings and victimization by other inmates
or jailers commonplace.
The funding system for psychiatric services, Dr Torrey went on to say,
guarantees the failure of services, with no fiscal incentives to provide good
services. "Imagine," he said, "what services would look like if payments were
made on the basis of measurements of quality of life, number employed, decrease
in homelessness, etc." Meanwhile, pharmaceutical companies "charge excessive
prices and make excessive profits," to the tune of 30 percent of revenues,
making the industry the most profitable, according to an editorial he cited from
the 2000 New England Journal of Medicine. Risperdal, he noted, costs half as
much in France, Zyprexa half as much in Canada, and Clozaril one-sixth as much
in Spain. "The budgets of mental health centers, county and state mental health
programs, and VA programs have been devastated by the rapidly rising drug
costs," he concluded.
As for managed care: "Managed care has almost nothing to do with care. Rather,
it is managed costs." The average time for a stay in a psychiatric hospital has
dropped from three and a half weeks in 1990 to one and a half weeks in 2000,
notwithstanding the fact that for 30 percent of patients the average time to
respond to psychiatric medication is two weeks. Meanwhile, United Behavioral
Health CEO Saul Feldman PhD lives in a penthouse atop San Francisco's Four
Seasons Hotel while his boss, William McGuire MD, CEO of the parent company
United Health Group, received total compensation in 2000 of $54.1 million, not
including unexercised stock options, equal to or greater than the total mental
health budgets of nine states.
"In summary," said Dr Torrey, "managed care is about wealth, penthouses,
increased stock options, and making a fortune. It is not about health,
clubhouses, increased job options, or treating the unfortunate."
In acknowledgment of his audience, Dr Torrey said advocacy is the basis for hope
for the future, and urged everyone to become wolves. "A sheep merely wants to
make friends," he concluded. "A wolf wants to make changes."
ABOUT THOSE BIRD STUDIES
Many of those at this year's NAMI conference recalled Nobel Laureate Eric Kandel
MD's masterful presentation on his studies of the brains of snails from
last year's NAMI conference, so they were prepared to apply a liberal heaping
of salt to Dr Torrey's references to NIMH bird brains. Moreover, the same
audience responded positively two days later to Richard Nakamura PhD, acting
director of the NIMH, who related how one study of bird song led to the
discovery of neurogenesis (growing new brain cells), a process that was
considered impossible until a short time ago. "It all got started," he told an
appreciative audience, "because some smart scientist asked a ridiculous
question."
HOW THE NIMH SPENDS ITS MONEY
The NIMH has a $1 billion budget, Dr Nakamura, related, making it the
eighth-largest of the 20 health institutes, funding 2,000 grants based on expert
peer review. Of the many voices the NIMH must listen to, Dr Nakamura noted, the
President and Congress are the most important, for "if we don't listen to
them, they can turn one billion dollars into zero dollars." Also providing input
is the Health and Advisory Council, chaired by HHS Secretary Tommy Thompson, of
which NAMI President Jim McNulty is a member, as well as an NIMH roundtable of
advocacy groups, plus other government bodies, such as the President's
newly-appointed Commission on Mental Health.
One recent major change at the NIMH, Dr Nakamura reported, is a new model for
clinical trials. In the past, only a person with "pure" depression, for
instance, would qualify for a depression trial. Now, "real people with multiple
problems come into these trials."
A PERSONAL MISSION
Scientists are sometimes seen as having different interests than the mental
health community, Dr Nakamura observed. Then he disclosed that his grandfather
committed suicide, and three siblings and his father have bipolar. "I'm
completely dedicated to eradicating these illnesses," Dr Nakamura told an
cheering audience in no uncertain terms. "We are all working on these problems
together, and together we will solve them."
NEW EMPHASIS
Sometimes the world listens to its prophets without acknowledging them, which
may be the case with the NIMH and Dr Torrey. Dr Nakamura's presentation made
it clear that the NIMH was changing its emphasis to fund research aimed at
reducing the burden of mental illness. In another session, Jim McNulty,
President of NAMI, echoed many of Dr Torrey's complaints by pointing out some
of the current shortcomings on the NIMH research agenda, including the paucity
of studies relating to bipolar. At the same session, Dennis Charney MD, Chief of
the NIMH's recently-established Mood and Anxiety Disorders Program, indicated
he was listening:
In a two-year process that involved consultation with NIMH staff, 119 outside
scientists, plus consumers and advocates, Dr Charney reported that the Mood and
Disorders Program has come up with a strategic plan to be published later this
year in the Journal of Biological Psychiatry. The plan's mandates include:
Discover the risk genes for bipolar; apply neuroscience and neurobiology to our
understanding of mood disorders; develop novel animal models to advance our
understanding of mood disorders; learn more about childhood disorders and
late-onset illness; find new pharmacologic treatments; study psychosocial
interventions; improve methods of clinical trials; and overcome significant
barriers to care.
The plan, Dr Charney said, runs the gamut "from molecules to society." He
predicts that in five to 10 years we will discover the risk genes for bipolar.
"This plan," he promised, "and the money that goes with it will make it happen."
MEANWHILE ...
Charles Curie MA, ASW, administrator of the Substance Abuse and Mental Health
Services Administration (SAMHSA), told a NAMI forum that it takes from 15 to 20
years for medicine research to reach the community. One of SAMHSA's high
priorities, he related, is to work with the NIMH in doing real services research
that impacts people's lives.
Also speaking was Michael Hogan, PhD, head of the Ohio Department of Mental
Health, who in May was appointed by President Bush to chair the
newly-established Freedom Commission on Mental Health, with a mandate to report
back to the President in 10 months. "The President understands," he said.
WORTH THE WHOLE BILLION BUDGET
Get used to hearing the name, Husseini Manji MD, who has been mentioned several
times in this Newsletter concerning the eye-opening studies he and his
colleagues have been conducting at the NIMH. At a session at the NAMI
conference, Dr Manji gave what amounted to a master's class for dummies on the
fine points of the neuroscience of mood disorders. Forget the neurotransmitters,
was the gist of his message. They are merely keys that unlock what is going on
inside the neuron, "where all the action is."
Referring to current drugs that work on neurotransmitters, he asked, "Why start
out there? Why not start down here [ie inside the nerve cell]?" A potential
target inside the nerve cell includes the protein kinase C (PKC) pathway, which
is implicated in nerve cellular excitability. The anticancer drug tamoxifen
inhibits PKC and has been found to significantly reduce mania scores in one
small study.
Paradoxically, Dr Manji's team uses old drugs - namely lithium and Depakote -
on rats to identify targets for next generation drugs. To their surprise, a gene
chip micro-array revealed that both lithium and Depakote switched on a growth
and protective protein called bcl2 in the brain cells of rats. Recent
discoveries have found that mood disorders cause nerve cell shrinkage, but Dr
Manji's findings indicate this damage may be reversed.
There are 10 different targets inside the neuron that we did not even suspect a
few years ago, Dr Manji concluded. Eight of these targets are now being actively
investigated.
PARTING SHOT
Suzanne Vogel-Scibilia MD is a Pennsylvania psychiatrist with bipolar and a NAMI
board member. She related to the NAMI conference how once she suffered chest
pains while out of town. The doctor in the emergency room insisted she was
having a panic attack. Suzanne, who had experienced panic attacks before,
insisted she was not. "I'm a doctor and I'm telling you you're having a
panic attack," the doctor asserted, to which Suzanne replied: "I'm a
psychiatrist and I say I'm not."
This wasn't the end of the matter: "Now he says I'm delusional," she joked.
Suzanne was finally able to get a chest x-ray that confirmed pneumonia, only to
have the same doctor refuse to acknowledge his error and throw her out of the
emergency room. A technician the next day contacted her and advised her to come
back in, but she would have none of it. She would get treatment back at her home
town, where people knew her.
"All I want as a consumer," she concluded, "is to be treated just like everybody
else."
SEGUE
Lots more on the NAMI conference next week. Now back to regular programming ...
ZYPREXA-DIABETES
A Duke University survey of the
FDA'sMedWatch
and other data over eight years has identified 289 cases of diabetes in patients
who had been given Zyprexa. Of these, 225 were newly diagnosed. Seventy-one
percent of the cases occurred within six months of starting the drug. There were
23 deaths.
Said the study's co-author, P Murali Doraiswamy MD, in an interview with
Health News Digest: "While our report does not prove a causal relationship
between the drug and diabetes, doctors should be aware of such potentially
adverse effects."
QUIZ
What is the greatest killer of pregnant women and new mothers?
(Answer further down.)
STAYING ON YOUR ANTIDEPRESSANT
Newsletter 4#19 reported on an APA symposia by Michael Thase MD of the
University of Pittsburgh et al that emphasized the need for remission as a goal
in treating depression as opposed to response, implying the necessity of
long-term antidepressant treatment. Not so fast, says Giovanni Fava MD of the
University of Bologna and the State University of New York at Buffalo. In an
editorial in Psychotherapy and Psychosomatics, Dr Fava argues that the evidence for
long-term antidepressant use isn't clear, and that some studies have shown the
drugs are most effective during the acute (initial) phase of treatment. Dr Fava
also attributes the popularity of the newer antidepressants to drug company
propaganda rather than need or clinical evidence.
BRAIN IMAGING
A Clinical Neuroscience Research Center and Institute of Psychiatry (UK)
study
published in the AJP of the brain scans of 25 patients in the initial phases of
psychosis showed parts of a section of the brain mainly related to memory and
recognition of speech (the temporal lobe) had shrunk compared with those of
healthy people. According to CNRC Director Professor Tonmoy Sharma: "The
findings ... suggest that brain imaging could become a powerful predictor of
future illness."
GOD POWER
A Department of Veterans Affairs Medical Center in Philadelphia/University of
Pennsylvania
survey
of 835 AfricanAmericans, most living at or below the poverty line, has found 90
percent reported that they "obtained a great deal of support and comfort from
their religion," and this support "was related to overall lower mental health
problems - including thoughts of suicide."
(MIS)TREATMENT
What is wrong with this picture?
Last week the UK government published a
draft
Mental Health Bill that would allow the detention of mentally ill people
deemed dangerous and force them to undergo treatment, even if doctors are unsure
whether treatment will help.
Meanwhile,
Rethink
- formerly the National Schizophrenia Fellowship - reports that in some cases
the waiting time for people showing early signs of severe mental illness is two
years or more. Even individuals showing clear signs of psychosis waited on
average 18 months before getting help, while one in three people seeking help
are turned away.
MAJOR CHANGES AT NDMDA
The National Depressive and Manic-Depressive Association has announced plans to
widen its mission to include greater focus on the illnesses from birth to late
life, as well as co-occurring illnesses (mood disorders with other mental
illnesses), dual diagnosis (mood disorders with alcohol or substance abuse),
comorbid illnesses (mood disorders with other physical illnesses), and family
members.
The NDMDA will also be changing its name. Surveys and focus groups are in
progress. To make your own voice heard, email
mailto:letusknow@ndmda.org or visit the NDMDA website at:
http://www.ndmda.org/
LEXAPRO
Three pooled studies of 1321 depressed patients over eight weeks funded by
Forest Laboratories have found that 10 to 20 mg of Lexapro a day led to
"significantly greater" improvement in depression symptoms compared to 20 to 40
mg a day of Celexa, especially in severely depressed patients. Fifty percent of
the severely depressed patients on Lexapro responded vs 40 percent on Celexa vs
35 percent on a placebo.
Lexapro is a classic example of less is more - a single isomer of Celexa, both
which are manufactured by Forest Laboratories. Two pre-clinical studies on rats
have shown the drug increases brain serotonin levels to a much higher level when
compared to Celexa and other SSRIs. According to Forest Laboratories: "This data
suggest that SSRIs should not be considered a homogenous group of compounds and
that SSRIs may contain different clinical properties."
The drug is expected to receive final approval from the FDA in the very near
future.
ARIZA
An eight-week
study
funded by Organon Inc of 212 severely depressed outpatients taking Ariza
responded better than the placebo group at all points in the study except week
eight. However, a subset of 106 patients presenting with oversleeping and/or
overeating ("probable atypical") decreased their MADRS depression scores by 12.2
points vs 7.5 points in the placebo group.
Ariza is a serotonin 1A agonist - a chemical cousin of Buspar - that is believed
to have a faster mechanism of action than other antidepressants. Manufacturer
Organon - which also markets Remeron - is awaiting FDA approval.
SUGAR OK
A Duke University study of subjects on high and low-sugar diets found no reports of mood swings or hyper behavior,
nor raised blood sugar or diabetes as a result of high sugar intake. In an
interview with Health News Digest, study author Richard Surwit PhD attributed
the myth of "sugar high" to World War II government propaganda aimed at keeping
people from eating the sweet stuff, which was in short supply.
STRANGE BUT TRUE
Promise you won't laugh:
A State University of New York at Albany
study of 293 women found those whose sexual partners did not regularly use
condoms were less depressed than those who used condoms during sex. The study's
authors suggest that semen may enhance mood when absorbed through the lining of
the vagina.
TURF WARS
New Mexico's new law allowing specially-trained psychologists to prescribe
medications came into effect this week. It may take a year or more for the
handful of psychologists who have signed up for training to become certified.
Paul Applebaum MD, president of the American Psychiatric Association, cited a
case where a psychologist would be out of his depth: A recent manufacturer's
and FDA letter to all physicians warned of possible liver toxicity. Said Dr Applebaum to the
Washington Post "Any physician who gets that letter has a framework to fit
that information. They understand liver function, the urea cycle, the signs of
hepatic encephalopathy. Psychologists have none of that."
ANSWER TO QUIZ
A British study reported
in WorldEntertainment News Network has found suicide to be the main cause of
death among pregnant women and new mothers. The report notes many mothers or
pregnant women opt for violent deaths rather than overdosing on pills.
A SALT AND BATTERY
In recent years drug companies have ignored
lithium as they promoted their anticonvulsants as mood stabilizers. Now it
appears lithium is striking back. Last week a chemical drum exploded at the
Pfizer Corp research lab in Groton, Connecticut, blowing the roof off a
warehouse and injuring seven people. The drum was filled with a solvent
containing - lithium.
NDMDA CONFERENCE
Please keep Aug 9-11 open for the National Depressive and Manic-Depressive
Association conference in Orlando. Listen to great speakers, and talk openly
among people who truly understand. For more details, please visit:
http://www.ndmda.org/conference.html/
MCMAN'S WEB
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http://www.mcmanweb.com/
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