So Apparantly I'm Bipolar

According to a new paper, yours truly is bipolar.





I've written before of my experience of depression, and the fact that I take antidepressants, but I've never been diagnosed with bipolar.



I've taken a few drugs in my time. On certain dopamine-based drugs I got euphoric, filled with energy, talkative, confident, with no need for sleep, and a boundless desire to do stuff, which is textbook hypomania. So I think I know what it feels like, and I can confidently say that it has never happened to me out of the blue.



On antidepressants, I have had some mild experiences of this type. Ironically, the closest I've come to it was when I quit an SSRI antidepressant. I've also experienced periods of irritability and agitation on antidepressants. Either way, that's antidepressants. Bipolar is when you get high on your own supply of neurotransmitters.



Well, it used to be. Jules Angst et al have got some new, broader criteria for "bipolarity" in depression. They say that manic symptoms in response to antidepressants do count, exactly like out-of-the-blue mania.



What's more, under the new "Bipolar Specifier" criteria, there's no minimum duration. Under existing criteria the symptoms have to last 4 or 7 days, depending on severity. Under the new regime if you've ever been irritable, high, agitated or hyperactive, on antidepressants or not, you meet "Bipolar Specifier" criteria, so long as it was marked enough that someone else noticed it.



All you need is:

an episode of elevated mood, an episode of irritable mood, or an episode of increased activity with at least 3 of the symptoms listed under Criterion B of the DSM-IV-TR associated with at least 1 of the 3 following consequences: (1) unequivocal and observable change in functioning uncharacteristic of the person’s usual behavior, (2) marked impairment in social or occupational functioning observable by others, or (3) requiring hospitalization or outpatient treatment.

The bipolar net just got bigger. And they caught me in it. Me and 47% of depressed people in their study. They recruited 509 psychiatrists from around the world, and got each of them to assess between 10 and 20 consecutive adult depressed patients who were referred to them for evaluation or treatment. A total of 5635 patients were included.



Only 16% met existing DSM-IV criteria for bipolar disorder, so the new system with 47% identified an "extra" 31%, trebling the number of bipolar cases.



A cynic would say that this is a breathtaking piece of psychiatric marketing. You give people antidepressants, then you diagnose them with bipolar on the basis of their reaction to those drugs, thus justifying selling them yet more drugs.



The cynic would not be surprised to learn that this study was sponsored by pharmaceutical company Sanofi.

All investigators recruited received fees, on a per patient basis, from sanofi-aventis in

recognition of their participation in the study....The sponsor of this study (sanofi-aventis) was involved in the study design, conduct, monitoring, data analysis, and preparation of the report.

In fairness, the authors do show that patients meeting their criteria tend to have characteristics typical of bipolar people. And they show that their system is at least as good as DSM-IV at picking out these cases:



For example, DSM-IV bipolar patients had a younger age of onset than DSM-IV depressed ones. "Bipolar specifier" patients did too, compared to the 53% who didn't meet the criteria. Same for a family history of manic symptoms, multiple episodes, and shorter episodes. All of those are pretty well established correlates of bipolar disorder.



That's fine, and the results are better than I expected when I picked up this paper. But all this shows us is that the bipolar specifier was no worse than the DSM-IV criteria as applied in this study.



It doesn't tell us whether either was any good.



DSM-IV criteria were used in a mechanical cookbook fashion - symptoms were assessed by the psychiatrist, written down, sent back to the study authors, who then diagnosed them if they ticked enough boxes. Is that a good approach? We don't know.



Most importantly, we have no idea whether these people would do better being treated as bipolar rather than as depressed. The difference being that bipolar people get mood stabilizers. Maybe these people would benefit from mood stabilizers, maybe not. Existing literature on mood stabilizers in bipolar people can't be assumed to generalize to these 47%.



In the discussion, the authors argue that antidepressants are not much good in bipolar people, whereas mood stabilizers are. Fun fact: Sanofi make many of the most popular formulations of valproic acid/valproate , a big selling mood stabilizer.



I think that is no coincidence. Maybe that sounds crazy, but hey, what do you expect? I'm bipolar.



Angst J, Azorin JM, Bowden CL, Perugi G, Vieta E, Gamma A, Young AH, & for the BRIDGE Study Group (2011). Prevalence and Characteristics of Undiagnosed Bipolar Disorders in Patients With a Major Depressive Episode: The BRIDGE Study. Archives of general psychiatry, 68 (8), 791-798 PMID: 21810644

So Apparantly I'm Bipolar

According to a new paper, yours truly is bipolar.





I've written before of my experience of depression, and the fact that I take antidepressants, but I've never been diagnosed with bipolar.



I've taken a few drugs in my time. On certain dopamine-based drugs I got euphoric, filled with energy, talkative, confident, with no need for sleep, and a boundless desire to do stuff, which is textbook hypomania. So I think I know what it feels like, and I can confidently say that it has never happened to me out of the blue.



On antidepressants, I have had some mild experiences of this type. Ironically, the closest I've come to it was when I quit an SSRI antidepressant. I've also experienced periods of irritability and agitation on antidepressants. Either way, that's antidepressants. Bipolar is when you get high on your own supply of neurotransmitters.



Well, it used to be. Jules Angst et al have got some new, broader criteria for "bipolarity" in depression. They say that manic symptoms in response to antidepressants do count, exactly like out-of-the-blue mania.



What's more, under the new "Bipolar Specifier" criteria, there's no minimum duration. Under existing criteria the symptoms have to last 4 or 7 days, depending on severity. Under the new regime if you've ever been irritable, high, agitated or hyperactive, on antidepressants or not, you meet "Bipolar Specifier" criteria, so long as it was marked enough that someone else noticed it.



All you need is:

an episode of elevated mood, an episode of irritable mood, or an episode of increased activity with at least 3 of the symptoms listed under Criterion B of the DSM-IV-TR associated with at least 1 of the 3 following consequences: (1) unequivocal and observable change in functioning uncharacteristic of the person’s usual behavior, (2) marked impairment in social or occupational functioning observable by others, or (3) requiring hospitalization or outpatient treatment.

The bipolar net just got bigger. And they caught me in it. Me and 47% of depressed people in their study. They recruited 509 psychiatrists from around the world, and got each of them to assess between 10 and 20 consecutive adult depressed patients who were referred to them for evaluation or treatment. A total of 5635 patients were included.



Only 16% met existing DSM-IV criteria for bipolar disorder, so the new system with 47% identified an "extra" 31%, trebling the number of bipolar cases.



A cynic would say that this is a breathtaking piece of psychiatric marketing. You give people antidepressants, then you diagnose them with bipolar on the basis of their reaction to those drugs, thus justifying selling them yet more drugs.



The cynic would not be surprised to learn that this study was sponsored by pharmaceutical company Sanofi.

All investigators recruited received fees, on a per patient basis, from sanofi-aventis in

recognition of their participation in the study....The sponsor of this study (sanofi-aventis) was involved in the study design, conduct, monitoring, data analysis, and preparation of the report.

In fairness, the authors do show that patients meeting their criteria tend to have characteristics typical of bipolar people. And they show that their system is at least as good as DSM-IV at picking out these cases:



For example, DSM-IV bipolar patients had a younger age of onset than DSM-IV depressed ones. "Bipolar specifier" patients did too, compared to the 53% who didn't meet the criteria. Same for a family history of manic symptoms, multiple episodes, and shorter episodes. All of those are pretty well established correlates of bipolar disorder.



That's fine, and the results are better than I expected when I picked up this paper. But all this shows us is that the bipolar specifier was no worse than the DSM-IV criteria as applied in this study.



It doesn't tell us whether either was any good.



DSM-IV criteria were used in a mechanical cookbook fashion - symptoms were assessed by the psychiatrist, written down, sent back to the study authors, who then diagnosed them if they ticked enough boxes. Is that a good approach? We don't know.



Most importantly, we have no idea whether these people would do better being treated as bipolar rather than as depressed. The difference being that bipolar people get mood stabilizers. Maybe these people would benefit from mood stabilizers, maybe not. Existing literature on mood stabilizers in bipolar people can't be assumed to generalize to these 47%.



In the discussion, the authors argue that antidepressants are not much good in bipolar people, whereas mood stabilizers are. Fun fact: Sanofi make many of the most popular formulations of valproic acid/valproate , a big selling mood stabilizer.



I think that is no coincidence. Maybe that sounds crazy, but hey, what do you expect? I'm bipolar.



Angst J, Azorin JM, Bowden CL, Perugi G, Vieta E, Gamma A, Young AH, & for the BRIDGE Study Group (2011). Prevalence and Characteristics of Undiagnosed Bipolar Disorders in Patients With a Major Depressive Episode: The BRIDGE Study. Archives of general psychiatry, 68 (8), 791-798 PMID: 21810644

Rendell, Giuliani call for "early detection system" for mental illness and guns

By Michael J.W. Stickings

The Hill:

Two high-profile politicians [yesterday] called for sweeping reforms to the nation's mental health system that would prevent individuals deemed ill from legally purchasing firearms.

Had numerous concerns about alleged gunman Jared Lee Loughner’s mental status placed him on a list restricting his ability to buy a gun, his Jan. 8 rampage might have been prevented, said former New York City Mayor Rudy Giuliani, a Republican, and Pennsylvania Gov. Edward Rendell, a Democrat.

During a "Face the Nation" appearance, Rendell called for an "early detection system" designed to keep mentally unstable individuals from buying guns. 

Basically, if you've attended more than one Tea Party event (because you could have attended one just by accident) or if you're a Tea Party-backed candidate for the GOP, you shouldn't be able to buy a gun. Period.

I'm kidding... of course. (Ahem.)

Actually, in a country that refuses to do anything about guns and gun violence, this was an admirable display of bipartisan support for a rational response to the Arizona shooting. Giuliani, once something of a moderate but now a Republican hard-liner, even talked about the country's "inability to deal with mental illness."

I would just note that while there does need to be a "rational debate" on gun control, as Rendell said, as well as a serious effort to address mental illness, the Arizona shooting -- an assassination attempt on a politician -- wasn't just about some lone crazy guy getting hold of a semi-automatic pistol with a high-capacity ammunition clip. It was also about the right's culture of violence, both in rhetoric and in ideology, and about the extent to which that culture has come to shape American politics and define conservatism.

As I wrote last week, while it certainly appears to be the case that the (alleged) killer, Jared Lee Loughner, is "deranged" (to use a loaded and hardly clinical term), as well as that he was not a card-carrying member of the Tea Party or GOP, it is wrong, I think to treat him as a detached loner who acted in a vacuum of his own derangement. To do that is to ignore context, to ignore the bigger picture, the "national climate."

In other words, there may be no direct connection between conservatism and the shooting, but that does not necessarily mean that what Loughner did (or, rather, is charged with doing) may be detached entirely from the broader, right-wing political context that may very well have informed his thinking, or his derangement, to some degree.

"You can't outsmart crazy"

By Edward Copeland

With those words, Jon Stewart gave another eloquent speech at the beginning of Monday night's Daily Show, dispensing with humor to address Saturday's horrific events in Tucson.

With each passing hour and day since alleged gunman Jared Lee Loughner opened fire on Rep. Gabrielle Giffords, critically injuring her, killing six and wounding 14 others, it becomes clearer that this 22-year-old man was not a political partisan but someone who was severely mentally ill. With Arizona government offices finally open Monday, The Washington Post finally was able to answer one simple question that's not open to debate: his voter registration. The answer turns out to be that he was a registered independent but was considered inactive because he hadn't bothered to vote in such a long time, including in November. Hardly indicative of a Tea Party participant.

I am guilty of jumping to conclusions. With the precursors without body counts such as smashed windows, threats, cut gas lines, it was an easy assumption to make. However, in my horror of the moment I forgot the old line about what happens when you assume: it makes an ass out of u and me. Subconsciously, there probably was part of me as there consciously was in many others who wanted this tragedy to turn out to be that way for political advantage. I may disagree with the Tea Party, believe them to be terribly misinformed and inflamed by the likes of Glenn Beck, but they aren't all homicidal lunatics.

When so many on the left criticized Jon Stewart's rally, claiming he was trying to make both sides equivalent, in the wake of Saturday's events, now he seems more right than ever. Keith Olbermann's Saturday special comment didn't say so explicitly, but if you read between the lines, it was a bit of a mea culpa for his own role. As Sarah Palin rushed to delete her graphic with the gunsight over Giffords' district, Daily Kos also had to delete a post where one of Giffords' constituents said that Giffords was "dead to me" because she voted against Nancy Pelosi for House minority leader.

Already, both sides are starting to revert to old habits. Because we on the left rushed to link the act of a madman to the politics of those we oppose, now those on the right revert to defensive mode and attack us. Hopefully, someone can stop this quickly. This is an opportunity for everyone to step back, take a breath and restore civility to the political process. I'm not saying compromise your principles, but it's long past time where both sides stop treating political opponents as the enemy. As it's been said many times, you can disagree without being disagreeable. The political climate probably didn't set Loughner off, but both parties need to look at themselves critically and seriously.

I hope that people take Pima County, Ariz., Sheriff Clarence Gupnik to heart and start rejecting the Becks and Limbaughs, but the only way that happens is when they get hit where it really hurts: the wallet. Beck has shown those signs with the loss of lots of sponsors, being taken off a big New York radio station and even dropping numbers on Fox News. I wish their listeners realized they were in it for the money, but oh well.

What really needs to be addressed seriously is the fact that this country has a gun problem and it's had a gun problem for a long time. A man rejected by the military, kicked out of college and who worried others around him was still allowed to legally purchase his Glock and, more importantly, his high-volume ammunition clips. He had three clips which had 33 rounds each. These sorts of clips were illegal under the assault weapons ban which was allowed to expire during the Bush Administration. If that law were still in place, he could only have purchased clips that held 10 rounds, meaning he would have to reload more frequently and the bloodshed would have been less. I hope the NRA and their friends in Congress are proud. Right now, Arizona is considering allowing faculty and college students to carry concealed weapons without a permit.

We also have to improve our ability to treat the mentally ill. In a rare moment of a television newsperson saying something profound, Lester Holt did the other day when he said that in the end, the motive doesn't matter. Six people are still dead, including a 9-year-old student council president born on 9/11.