McMan's
Depression and Bipolar Weekly
Mar 6, 2002 Vol 4 No 10
JANE'S DAY IN COURT
Anyone who has experienced depression or bipolar
knows it is not just a mental illness. The body either shuts down or revs up,
affecting how we eat, sleep, and interact with our surroundings. Depression and
stress seem to kickstart one another, which may account for our increased
exposure to heart disease, diabetes, stroke, bone marrow loss, and more. At last
year's Fourth International Conference on Bipolar Disorder, Robert Post MD of
the NIMH reported that those who have bipolar lose seven years of life,
independent of suicide. Thanks to brain scans and postmortem studies of brains,
we now know it's not just all in our heads, that certain parts of our brains
physically decrease in volume, and that neurons atrophy and die.
Meanwhile, genetic studies are closing in on DNA smoking guns.
Yes, you know all this, I know all this, but would we ever be able to prove it
in court? Enter the model litigant, Jane
Fitts. In 1982, she began employment as an attorney for Federal National
Mortgage Association (Fannie Mae). In 1995, she was diagnosed with bipolar and
was unable to keep working. Under her benefit plan, physically disabled
employees are eligible to collect benefits until age 65, but those with
disabilities due to mental illness are limited to 24 months. When Fannie Mae
informed Jane that her benefits would only run for a short time, she brought
suit in a federal court in the District of Columbia, claiming that her bipolar
is a physical illness.
Jane turned up in court with several brain scans that indicated that the
parietal lobe on the left side of her brain was atrophied beyond normal
expectations. The scans also showed abnormal brain wave activity on the left
side of the brain. The physical changes to her brain, Jane asserted, meant her
bipolar is not a "mental disorder" as defined by the terms of her
benefit plan. Then she had her star witness, or rather a written declaration
from, none other than Frederick Goodwin MD, former head of the NIMH and
co-author of the definitive work on bipolar disorder. In the words of the court:
"According to Dr Goodwin, the disorder is associated with chemical
imbalances in the brain and other abnormal brain activity ... While Dr Goodwin
stops short of saying that bipolar disorder has physical causes rather than
merely physical correlations, he ultimately concludes that bipolar disorder is a
physical illness because it is a disease afflicting a physical organ of the body
just like diseases affecting the heart, the kidneys or the liver."
Another expert witness, Dr Suzanne Griffin, who has treated Jane since 1996,
testified that "depression is as physical as heart disease ..."
The court also noted that the DSM-IV rejects the distinction between mental and
physical illness, quoting: "... A compelling literature documents that
there is much 'physical' in 'mental' disorders and much 'mental'
in 'physical' disorders."
Ultimately, the court's decision turned on the legal principle of "contra
proferentem", that is, if a term in the contract is ambiguous, it must be
interpreted against the one who drafted the contract and in favor of the party
who provides a reasonable explanation. Here, the court ruled that since the
definition of mental illness in the policy ("mental, nervous or emotional
disease or disorder of any type") was vague, Jane's arguments should stand,
and judgment was entered in her favor.
Undoubtedly, Fannie Mae and everyone else in the business will be rewriting
their policies to define mental illness as including depression and bipolar,
thus severely restricting any precedent-establishing potential this case may
hold out. But in the wall that unfairly separates ourselves from the rest of
society, this case represents at least one brick that has been knocked loose,
and that's a start.
ANOTHER CASE
Elsewhere on the legal front, the Second
US Circuit Court of Appeals earlier this year ruled that the ability to
interact or get along with others constitutes a "major life activity"
within the meaning of the Americans with Disabilities Act, thus entitling a
woman with bipolar to sue her employer under the ADA. In 1996, Audrey Jacques
was fired for confrontational and irrational behavior with her supervisor.
Audrey claimed that her problems stemmed from her bipolar, and that her employer
had not provided reasonable accommodations for her.
ACCUTANE
According to an article in HealthScout: "Hoffman-La Roche Inc. and the US
Food and Drug Administration (FDA) have agreed on several changes to the drug's
package insert, the most notable being a brochure for prescribers dealing with
the potential psychiatric side effects of Accutane."
An updated "Warnings" section to the drug's product insert lists the
possibility of depression, psychosis, suicidal thoughts, suicidal attempts, and
suicide.
According to the FDA, 110 Accutane users have attempted suicide and 37 have
killed themselves.
THE COST OF BIPOLAR
A UK study
has estimated that the annual National Health Service cost of managing bipolar
in the UK to be nearly two billion pounds ($US 2.8 billion) and the indirect
costs to society nearly 10 times that at 17.7 billion pounds ($US 25.2 billion)
AFTER THE HYPE
According to a Health Media
article, the Royal College of Psychiatrists in the UK has altered advice stating
that Prozac and other leading antidepressants "are effective in 60 to 70
per cent of patients, to saying the drugs are successful in only 50 per cent of
cases."
DEPRESSION STUDY FLAWS
A Brown University study
of 346 depressed outpatients has found only 15 percent would have qualified for
a standard drug trial, yet 90 percent of those who would have been disqualified
were being prescribed antidepressants. Many studies exclude patients with
psychotic features, a history of manic episodes, suicide risk, unstable medical
illnesses, or a history of substance abuse
According to the study's lead author, Mark Zimmerman MD: "When you take any
medicine you assume it's been found to be effective for your condition. No one
knows for sure whether antidepressants are effective for most of the patients we
treat."
CANCER AND DEPRESSION
"As many as half of all cancer patients experience depressive
symptomatology that would qualify for clinical diagnosis. Physical symptoms of
the disease and declining physical abilities may cause depression and anxiety,
which can begin with diagnosis and continue throughout treatment." - Margot
E. Kurtz of the Department of Family and Community Medicine at Michigan State
University in Pscho-Oncology.
In a study of 228 lung cancer patients aged 65 and over, she and her colleagues
found:
42 percent of the women were depressed at the beginning of the study and 39
percent of the men, which declined to 33 percent and 31 percent, respectively.
The best predictors of serious depression were the severity of the patients'
cancer symptoms and the patients' social functioning. Not receiving radiation
therapy was also a good predictor of depression.
SLEEP AND DEPRESSION
A Laval University (Quebec) study
of 83 sleep apnea patients has found that 53 percent reported feeling depressed.
"It's probably a risk factor, but I would not go as far as saying it's a
cause," says the study's lead author, Professor Yves Lacasse. Up to 25
percent of the population may suffer from sleep apnea, with breathing stopping
briefly at least five times an hour. A more severe form, obstructive sleep apnea
in which interruptions occur more than 10 times an hour, affects four percent.
WELLBUTRIN
A multi-center study
of more than 227 obese but otherwise healthy men and women has found that those
taking 400 mg/day of Wellbutrin plus a lifestyle program lost 10.1 percent body
weight after 24 weeks vs 7.2 percent on 300/day Wellbutrin plus lifestyle vs
five percent on a placebo plus lifestyle. Those who stayed with the study for a
second 24 weeks lost an additional 7.2 and 6.4 percent of their body weight,
respectively.
PILL PUSHERS
The UK mental health charity Mind
reports that 98 percent of patients they surveyed reported that they were
prescribed medication by their GP despite the fact that less than one in five
had asked for it. More than half felt they had not been given enough choice such
as counseling and alternative therapies.
WHY WE GET CYNICAL
The website of Mylan Laboratories states: "When Mylan Pharmaceuticals was
founded in 1961, its mission was simple: to help make quality medicines more
affordable for patients who need them. That mission has not changed."
Ahem.
A Federal Court has
approved a $100 million settlement among Mylan Laboratories and 50 states plus
the Federal Trade Commission, acting on behalf of consumers. In late 1997, Mylan,
which produces generic versions of the antianxiety drugs lorazepam and
chlorazepate, conspired with the manufacturer of the active ingredient of both
these drugs to deny access of that ingredient to its competitors. Shortly after,
Mylan raised the price of lorazepam by amounts ranging from 1,900 percent to
2,600 percent. The price of a bottle of 500 one-mg tablets skyrocketed from
$7.30 to $191, with consumers paying even more at retail drug stores.
CLOZARIL
An article in Medscape
on the first of the atypical antipsychotics Clozaril (clozapine) is written
mainly in the context of schizophrenia, but is well worth checking out:
Sixty percent of patients unresponsive to or intolerant of other antipsychotics
respond to Clozaril, but its use has been greatly limited due to the risk of
agranulocytosis (a significant decrease in certain types of white blood cells).
The risk of agranulocytosis is less than one percent, and with periodic blood
monitoring drops to 0.38 percent. Data from the UK suggests the risk decreases
to 0.07 percent after one year. In the UK, the drug is licensed for
schizophrenia only after two other antipsychotics have failed.
Clozaril is rapidly absorbed and distributed, but its antipsychotic effect may
take several weeks to kick in, and its maximum effect may require several
months. According to the article: "In a one-year randomized trial of
clozapine versus treatment-as-usual among 39 bipolar patients, clozapine's
superiority was evident within the first six months of treatment and was
maintained throughout the duration of this study." Another study for 70
percent of schizoaffective patients achieved demonstrable improvement. The drug
is also supposed to benefit psychotic depression.
Tricyclic antidepressants, benzodiazepines such as Ativan, and
histamine-blockers such as Zantac should be used with caution when taking
Clozaril.
Surprisingly, the article mentioned nothing about extrapyramidal side effects
(EPS - movement disorders) or tardive dyskinesia (muscular twitches that are
part of EPS) that are associated in particular with older antipsychotics and to
a lesser extent with the atypicals. [Note to readers: Please feel free to
contact me at jmcmanamy@snet.net
to elaborate on this matter.]
ZYPREXA
Two items:
Eli Lilly has received approval from the European Union to market Zyprexa for
the treatment of moderate to severe mania. The drug is already licensed for
mania in ten countries, including the US.
According to Eli Lilly CEO Sidney Taurel on CNBC, the antipsychotic and
antimania drug Zyprexa represents more than 25 percent of the company's sales at
about $3 billion last year.
OMEGA-3
Three items:
We know that a steady diet of farm-raised beef is an invitation to a coronary,
but an article in the Denver Rocky Mountain News mentions alternatives that
include buffalo, "natural" beef, and grass-fed beef. Grass-fed buffalo
and cattle have higher levels of omega-3 and far less fat. A hundred grams of
buffalo meat, for example, has 1.37 grams of total fat compared to 17.06 grams
of total fat in the same amount of extra lean ground beef and 2.7 grams in the
same amount of roasting chicken.
An article in the Minneapolis Star Tribune waxes eloquent on the benefits of
flax, which is rich in omega-3. The Emperor Charlemagne was such a great fan of
the grain that he required his subjects to eat it. Ground flax seed can be
sprinkled on yogurt and a dash of flax oil can fortify a smoothie. Flax seed
contains just one type of omega-3, so it is advisable to keep eating fish. Most
capsules contain 1,000 mgs of flax oil, although it is not yet clear how much
flax the body needs. In addition to looking promising for treating depression
and bipolar, omega-3 is reputed to be good for the heart. Flax seed is also a
rich source in ligands (which may prevent some hormonally-related cancers) and
fibers (the oil alone does not have ligands or fiber). If you buy flax seeds, be
sure they are ground or that you grind them, as the body cannot digest the seed's
outer hull.
An Israeli study
of 20 patients with major depression has found that ethyl ester of
eicosapentaenoic acid, a purified form of EPA found in omega-3, resulted in
"highly significant benefits" compared to a placebo by week three.
REQUIEM
FOR A GOON
Before there was Robin Williams, before there was John Cleese, before there was
Jonathan Winters, there was Spike Milligan, creator of BBC radio's legendary
Goon Show, where wacky black humor was born and where Peter Sellers got his
start. According to an article in the London Mirror: "We all had this
lunatic sense of humor which I suppose was resentment of what the adult world
had done to us," which happened to be World War II, from which Milligan
suffered shell shock that probably triggered his bipolar which in turn resulted
in at least 10 breakdowns. "If people want to know where down is, tell them
Spike Milligan knows, " he once said. "Manic depression is a very
lonely journey."
Spike Milligan died last week at age 83.
MALE MENOPAUSE
Yes, it's real and has a name, "Irritable Male Syndrome", roughly
equating to grumpy old men and a drop-off in testosterone. According to Dr
Gerald Lincoln of Medical Research Council's Human Reproductive Sciences Unit in
Edinburgh, Scotland in an article in the Belfast News Letter: "Studies of
men who can't make their own testosterone, who are being treated with hormone
replacement therapy, have shown that when they stop taking their pills they
exhibit symptoms of depression." [Note: see also the entry under "From
the AJP" just below.]
FROM THE AJP
Postmortem brain studies of 15 teenage suicide victims suggest "that a
higher level of 5-HT2A receptors may be one of the neurobiological abnormalities
associated with teenage suicide."
A study found "total testosterone levels were lower in elderly men with
dysthymic disorder than in men with major depressive disorder and men without
depressive symptoms." MALE SUICIDE
A study in Psychiatric Services reports that between 1979 and 1997 firearms
accounted for 70 percent of suicides among males aged 15 to 19, and 64 percent
among males aged 20 to 24. During that same period, the rates and percentages of
suicides by African American males increased significantly more than among white
males.
ANDREA YATES
Mary Ellen writes:
I am so upset about Andrea Yates.
I actually looked her lawyer up on the internet and phoned to volunteer
testimony about what it is like to be so depressed/psychotic that you believe
the only way to "save" your kids (from you, terrible mother) is to
kill them - been there, done that in '94, but was - thank God - prevented,
first by a sensitive MD and then by skilled mental health pros.
In any case, I was told (of course) that witnesses were lined up long ago and
that all I could do was "pray" etc. However, the receptionist I spoke
with was very sympathetic when I said this "whole thing" was "so
misunderstood."
Glad for that. Sorry I can't be of REAL help. REALLY sorry for the moment that
prompted me to run to the internet search/phone: My husband, watching news of
the Yates trial, said, emphatically, "They ought to fry that bitch."
When I protested and tried to explain, he said, "So, she's got bad genes,
they need to be gotten off the face of the earth and not passed on."
Where the hell was he in '94 when I was planning to murder our kids and was
hospitalized and medicated accordingly? Who the hell did he think he was talking
to, other than the woman who passed these bad genes on to his offspring? I am
just STUNNED.
And similarly, whateverhisnameishusband Yates is saying he had no idea Andrea
was hearing voices, etc ...
STIGMA ALERTS
From NAMI's Stigma Busters newsletter:
Reporter Adam Housley on Fox Cable News commented on actors nominated for Oscars
who portray "bad role models", which included John Nash's character
played by Russell Crowe, described as "crazy". Other characters on the
list included a prostitute and a murderer. (Let Fox know what you think by
emailing adamhousley@yahoo.com
and Executive News Producer, Dennis Murray at: dennis.murray@foxnews.com.)
The NY Times crossword puzzle editor, Will Shortz, who has ignored NAMI's
complaints about such clues and answers as: "Candidate for a psych ward/Sicko."
(Complaints to John Rockwell, Arts and Leisure Editor at a+l@nytimes.com
Bill O'Reilly, host of Fox's "O'Reilly Factor", for numerous rants
against the homeless, those who use their mental illness as a defense in court,
and regarding the Andrea Yates trial. (You can register your disgust at oreilly@foxnews.com,
but be warned: people like O'Reilly feed off criticism.)
MCMAN'S WEB
Check out more than 170 articles on all aspects of depression and bipolar, plus
a bookstore, readers' forum, message boards, chat room and other features at: http://www.mcmanweb.com
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