McMan's Depression and Bipolar Weekly 

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July 31, 2001 Vol 3 No 30 

MOVING MOUNTAINS 

Anne O'Callaghan's son, Connor, became depressed and anxious in college, then experienced mood swings and began doing strange things. He went into psychotherapy for two years but kept sliding downhill. Anne, in the meantime, was told she was an "overfunctioning mother" and to back off. 

"What did we know?" she told a symposium at the NAMI Conference held in Washington DC in mid-July. 

A revolving door of psychiatric hospitals and homelessness followed for Connor, with no one talking of recovery, of restoring her son to his premorbid or pre-illness state. As a health professional, she knew that a patient's return to good physical health is weighed against standard benchmarks, but she could not find equivalent measures anywhere for mental illness. Finally, she found a halfway house with a rehab program which did wonders. Instead of lying down all day, Connor was starting to read again and take walks. Then Blue Cross/Blue Shield called and cut off the treatment. 

Anne then put together a profile of the "premorbid" Connor and sat down with a team of treating doctors and Blue Cross. The Blue Cross team turned her down immediately. "They did not open my booklet," Anne said. "They never looked at a clinical note. They were willing to deny him without looking at the clinical record. The decision was made before we walked in the door." 

Moreover, their doctor was not willing to stand up to Blue Cross, nor was the hospital nor was the halfway house. 

Bryant Welch JD, PhD, an attorney who specializes in suing managed care companies - sadly on behalf of deceased patients - warned that families get incredibly worn down in this system and that it's easy to let your guard down. The only way for managed care companies to make money, he asserted, is by denying care to those most in need. Moreover, the doctor is effectively gagged, for he's liable to get kicked out of the system if he takes up your cause. Doctors, he said, are becoming inured to the system and are giving recommendations they never would have given ten years ago. 

"Medical necessity" is the rod that managed care companies use to beat back claims. Managed care companies set their own criteria, with treatment decidedly less equal for the mentally ill despite the parity laws on the books. They have their own internal grievance programs, but because they are making a decision about a decision already made, as Darcy Gruttadaro JD, senior attorney for NAMI, pointed out, there is no objectivity. Forty-one states require an external independent grievance process, with wide variations from state to state. For Medicaid, federal law requires states to provide consumers with a fair hearing. 

Anne's lawyer advised her they probably wouldn't win, but ten days later Blue Cross' decision was reversed. Connor today is in independent living, working as a coach in school, and is back at Temple University with two semesters to complete. He has reconnected with friends, is social, and funny, and "well within the bounds of normality." 

All thanks to a mother willing to move mountains. 

MORE 

Not all people are as lucky as Connor. Bryant Welch brought up the case of a student who had been stabilized on Risperdal, but back in his home town on another plan he was taken off the drug and put on an older antipsychotic. Five days later, he hung himself. Risperdal was not excluded from the health plan's drug formulary, but first a patient had to fail on an older antipsychotic. "Imagine how this plays in a corporate board room," Dr Welch said. "See if it fails first." 

He had this to add about litigation strategy: If the doctor is against a patient, focus groups will believe the doctor. But managed care companies lack credibility with these same people. Therefore, keep the managed care company in the case. 

THE HEALING POWER OF WRITING 

Judith Hillman Paterson PhD told a NAMI workshop that writing "Sweet Mystery: A Southern Memoir of Family Alcoholism, Mental Illness, and Recovery" was extremely cathartic for her because it forced her "to peel away the denial." Nevertheless: "I thought when I finished I would be purged, free. In fact, a great sorrow washed over me." 

She didn't start writing the book until her father died. Her mother died when she was nine of what was probably a combination of severe depression and alcoholism, but depression was a blow-off word when she was growing up, frequently mentioned but having no meaning. Of her siblings, three are dead and one is brain damaged from alcohol. But what the book showed her was that she was looking at only half the picture, that it was more than just the alcoholism. 

Also: "My stance was that it harmed everyone in my family except me. If that wasn't denial." 

Five years ago, Judith Church Tydings, who recommends books for review in NAMI's Advocate, happened upon Dr Paterson's book, bought it, and put it aside. She picked it up a year later and found herself gripped by it. She, too came from a family of alcoholism and mental illness. "I can't tell you the impact the book had on me," she told the same audience. 

THE NEW BIOLOGY 

"We simply do not have enough psychiatrists to do the basic science that will serve you best ... It is very important to keep some people at the frontiers of science. What psychiatry did for me was to give me a perspective of the things that are really important. The new biology is going to revolutionize our knowledge of mental life." Eric Kandel MD, Nobel laureate, on receiving NAMI's Pioneer in Science Award. 

SEGUE

 And now back to normal programming ... 

CAUTION 

The Institute for Safe Medication Practices has reported 17 known medication errors due to confusion between the antidepressant Serzone and the antipsychotic Seroquel. 

Meanwhile GlaxoSmithKline has announced that it has changed the appearance of its container for the mood stabilizer Lamictal in an effort to minimize confusion with the antifungal agent Lamisil. Changes include a yellow cap and the following message: "CAUTION: Verify Product Dispensed." 

DRUGS AND HOT WEATHER 

The Milwaukee Journal Sentinel reports that of four Wisconsin residents who died in a recent heat wave, two had been taking lithium, a third had been taking the tricyclic antidepressant nortriptyline, and a fourth had been taking the antipsychotic Clozaril. Medical Examiner reports attributed their deaths directly to the drugs they were taking. 

Antipsychotic drugs, mood stabilizers, antihistamines, drugs used to treat Parkinson's, and tricyclic antidepressants are known to cause problems in extremely hot weather, according to the article. The article quotes John Gudeman of the Medical College of Wisconsin: "[The drugs] shut off your sweating mechanism. They shut off your temperature regulation. With those two things out of whack, your temperature can rise rapidly in high external temperatures. If the temperature goes to 100 degrees, your body temperature goes to 100 degrees. That's what actually causes the heatstroke." 

TEGRETOL 

Tegretol more than doubles the risk of major congenital anomalies during the first trimester of pregnancy according to a Hebrew University (Israel) study of 210 women who had taken the drug. The relative risk of congenital anomalies was 2.24 for women in the Tegretol group. Birth weights were also lower and congenital heart defects higher (2.9 percent prevalence vs 0.7 percent). 

The findings corroborate a 1999 Dutch study. Free registration to Medscape is required to access the above link. 

PUTTING A PRICE TAG ON IT 

A University of Texas at Houston study has estimated the present value of lifetime cost of bipolar disorder in the US at $24 billion. This includes medical care as well as unemployment and reduced earnings. Average cost per individual ranges from $11,720 for those with a single manic episode to $624,785 for those nonresponsive or with chronic episodes. 

THE MARK OF OPPRESSION 

An Iowa State University study of nearly 900 African-American families has found that African-American fifth graders who experienced discrimination were more likely to suffer symptoms of depression. Seventy percent of the children reported being insulted, 50 percent reported racial slurs, and 20 percent reported being threatened with violence. One-third of the kids felt sad or depressed and an equal proportion reported thoughts of death. 

The above link will put you on HealthScout's home page. 

UP IN SMOKE 

A St James Hospital (Dublin) study has found that cigarette smoking is more prevalent among bipolar patients with a history of psychotic symptoms than among those without such a history. Sixty-eight percent of the patients with a psychotic history were smokers vs 32 percent of those without a psychotic history. 

A University of New South Wales (Australia) study, on the other hand, found no relation between depression and smoking. 

Free registration to Medscape is required to access the first link. 

POETIC JUSTICE 

A computer program comparing the poems of nine poets who committed suicide vs nine who did not found those who committed suicide used many more first-person singular references and fewer first-person plural words than the non-suicidal poets. There was also a corresponding drop in references to other people. 

The suicidal poets included: John Berryman (1914-1972), Hart Crane (1899-1932), Sergei Esenin (1895-1925), Adam L. Gordon (1833-1870), Randall Jarrell (1914-1965), Vladimir Mayakovsky (1893-1930), Sylvia Plath (1932-1963), Sarah Teasdale (1884-1933) and Anne Sexton (1928-1974). 

The comparison poets included: Matthew Arnold (1822-1888), Lawrence Ferlinghetti (1919-present), Joyce Kilmer (1886-1918), Denise Levertov (1923-1997), Robert Lowell (1917-1977), Osip Mandelstam (1891-1938), Boris Pasternak (1890-1960), Adrienne Rich (1929-present) and Edna St. Vincent Millay (1892-1950). 

Previous research has found that suicide rates are much higher among poets than other writers and the general public, and that poets are more prone to depression and bipolar. 

"As a group, no one would call poets a particularly bubbly, chipper group," the study's author, James Pennebaker of the University of Texas, told ABC News. 

AMERICAN DREAM? 

Heinz Prechter was the classic American dream story. A NY Times article chronicles his arrival in the US from Germany with $11 in his pocket, and from there going on to become founder and chairman of ASC, Inc, which perfected the sunroof and developed the Dodge Viper. An ebullient personality, he raised millions for the GOP and hobnobbed with some of the most powerful people in the world. But none of this mattered in early July. Heinz was struggling with his third major depression, which he had succeeded in keeping secret from all but his family and closest associates. He had lost his interest in business and politics, then was a no-show at a major auto event and for a Presidential visit. On July 6, for all he had to live for, his distressed brain apparently convinced him otherwise and he wound up taking his own life. He was 59. 

IN THE BOARDROOM 

The same NY Times article notes: 

"Drs Jeffrey Lyon Speller and Tanya Korkosz, who have studied depression in corporate settings, estimate that up to 10 percent of senior executives have at least some symptoms of manic-depression, yet nine out of 10 of them go undiagnosed and untreated." 

NEWS FROM THE PIPELINE 

Neurocrine Biosciences and GlaxoSmithKline have signed a research and development agreement for CRF antagonists. CRF is involved in the release of stress hormones which are implicated in depression. Neurocrine Biosciences' NBI 34041 is in phase I trials for anxiety and depression. 

ALL THE WAY 

"The primary goal of treatment should be full remission of all depressive symptoms. Partial remission is not an acceptable outcome." Charles Nemeroff MD, PhD et al in an article in Medscape. The same article notes the rate of relapse following a single episode of major depression is approximately 50 percent, which rises with each subsequent episode. Accordingly: "In patients with a history of more than three episodes, indefinite therapy with an antidepressant should be seriously considered because of the very high risk of recurrence." 

Free registration to Medscape is required to access the above link.

SURPRISE SURPRISE 

An Oregon Health Sciences University study has found that SSRIs surprisingly cost less to treat patients than the lower-priced TCAs. Reasons include lower dose adjustments, single tablet regimens, and often shorter duration of treatment. Free registration to Medscape is required to access the above link. 

ANTIPSYCHOTICS 

An article in a special bipolar supplement to the BJP (not available on the web) by Dr John Cookson of the Royal London Hospital makes a strong case for the use of antipsychotics in treating mania: 

The APA Guidelines (1994) advise of the use of antipsychotics in mania only as adjuncts to mood stabilizers, but in Europe the Guidelines are viewed with skepticism. There, antipsychotics are widely regarded as first line treatment for mania. Nevertheless, the differences in approach may be more theoretical than real. In both the US and in Europe, surveys show that the majority of manic patients discharged from the hospital are still taking antipsychotic medication and remain on it after six months. 

Lithium has a lag in its effect, taking a few days to begin, and two to eight weeks to approach its full benefit, making lithium monotherapy risky for all but the mildest cases of mania in the early going. For lithium and Depakote, one study found few patients had a return to normal functioning within three weeks. 

Of the newer atypical antipsychotics: Clozapine has been found effective in open studies and one randomized trial, including treatment-resistant patients. Zyprexa has been found efficacious in both mania and mixed episodes. Geodon has been found effective in mania. Risperdal with Ativan in one trial was of similar efficacy to Haldol or lithium. Two recent three-week studies found Risperdal with lithium or Depakote more effective than a mood stabilizer with a placebo. A six-week study found Zyprexa with a mood stabilizer more effective than a mood stabilizer with a placebo, with patients in mixed states showing markedly greater rates of improvement. 

LITHIUM 

An article in the same BJP supplement highlights the strengths and weaknesses of long term lithium treatment. Authors Leonardo Tondo et al of the University of Cagliari (Italy) treated 360 patients with just lithium and followed them over an average of 14.3 years, including 8.3 before treatment and six years during treatment. The patient population included an even sampling of all bipolar types, including mixed and rapid-cyclers. The study found that lithium treatment reduced mania by 64 percent and depression by 46 percent. The duration for mania was reduced by 19 percent and for depression 32 percent.. Time spent ill was reduced by 56 percent overall, and the hospitalization rate fell by 82 percent. Nevertheless, only 29 percent of the patients in the study achieved complete remission. 

Bipolar II patients fared best, with only minor differences among the other bipolar groups. The study also found that treatment response did not significantly deteriorate on resumption of lithium after discontinuation. 

NDMDA CONFERENCE 

The National Depressive and Manic-Depression Association is hosting its annual conference, "Empowering Our Future," at the Renaissance Cleveland Hotel in Cleveland Aug 17-Aug 19. Speakers include some of the field's top researchers, psychiatrists, therapists, wellness practitioners, and advocates. The keynote presentation will be by Andrew Solomon, author of the highly-acclaimed new book, "The Noonday Demon: An Atlas of Depression," now number 12 on the NY Times nonfiction best-seller list. Olympic diver turned mental health activist Wendy Williams will deliver the concluding address. For more details and online registration, please click here. 

SURVEY 

One of my subscribers, Hannah, is conducting a confidential online survey about what consumers think of the information on depression that's available to them. The survey is part of her MA dissertation in librarianship. You can help out Hannah by going here. Hannah will be collecting responses until mid-August. 

MCMAN'S WEB 

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